Nursing Elites

1. A nurse is providing teaching about breastfeeding to a client who is postpartum. Which of the following instructions should the nurse include?

• A. Wash your nipples with soap after each feeding.
• B. Place your baby to your breast for 5 minutes every 4 hours.
• C. Ensure your newborn has at least six wet diapers per day.
• D. Give your newborn 30 mL of water between feedings.

Correct answer: C

Rationale: The correct answer is C: 'Ensure your newborn has at least six wet diapers per day.' Six or more wet diapers per day is an indicator that the newborn is receiving adequate breast milk, making this an important part of breastfeeding education. Choice A is incorrect because washing nipples with soap after each feeding can lead to dryness and cracking. Choice B is incorrect as babies should nurse on demand rather than on a strict schedule of 5 minutes every 4 hours. Choice D is incorrect as giving water to a newborn between feedings is not recommended and can interfere with breastfeeding.

2. A nurse is caring for a client who has a prescription for enalapril. The nurse should monitor the client for which of the following adverse effects of this medication?

• A. Bradycardia
• B. Hyperkalemia
• C. Hyperglycemia
• D. Tinnitus

Correct answer: B

Rationale: The correct answer is B: Hyperkalemia. Enalapril, an ACE inhibitor, can lead to hyperkalemia by reducing aldosterone levels, which results in potassium retention. Bradycardia (Choice A) is not a common adverse effect of enalapril. Hyperglycemia (Choice C) and tinnitus (Choice D) are also not typically associated with enalapril use.

3. A nurse is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. Which of the following actions should the nurse take first?

• A. Maintain IV access
• B. Obtain the client’s vital signs
• C. Contact the provider
• D. Stop the transfusion

Correct answer: D

Rationale: The correct answer is to stop the transfusion. When a nurse suspects an adverse reaction to a blood transfusion, the priority is to stop the infusion immediately to prevent further harm to the client. Maintaining IV access and obtaining vital signs can be important steps but should come after stopping the transfusion to ensure the client's safety. Contacting the provider is necessary but not the first action to take in this situation. Therefore, the nurse should prioritize stopping the transfusion to address the potential adverse reaction.

4. A client is being taught about the use of levothyroxine. Which of the following should be included?

• A. It should be taken on an empty stomach
• B. Monitor for signs of hyperthyroidism
• C. It is a pain reliever
• D. It should be taken in the morning

Correct answer: B

Rationale: When educating a client about levothyroxine, it is important to emphasize the need to monitor for signs of hyperthyroidism. Levothyroxine should be taken on an empty stomach, preferably in the morning, to maximize its absorption. Choice A is incorrect as it should not be taken with food. Choice C is incorrect as levothyroxine is not a pain reliever. Choice D is incorrect as levothyroxine is usually taken in the morning.

5. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL per hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.

Similar Questions