Nursing Elites

1. A nurse is reviewing the medical record of a client who is at 30 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 140/90 mm Hg
• B. 1+ pitting edema in the lower extremities
• C. Weight gain of 2.3 kg (5 lb) in 1 week
• D. Mild headache

Correct answer: C

Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening preeclampsia due to fluid retention, which can lead to serious complications. This finding should be reported promptly to the provider for further assessment and intervention. Blood pressure of 140/90 mm Hg is high but may not be an immediate concern for a client with preeclampsia at 30 weeks. 1+ pitting edema in the lower extremities is common in pregnancy, especially in the third trimester, and may not be a significant finding in isolation. A mild headache can be a common symptom in pregnancy and may not be indicative of worsening preeclampsia unless accompanied by other concerning signs.

2. A client who is taking phenytoin is being taught about contraceptive options. Which of the following statements should the nurse make?

• A. You should use a backup method of birth control while taking phenytoin.
• B. Phenytoin can decrease the effectiveness of oral contraceptives.
• C. You should stop taking phenytoin while using oral contraceptives.
• D. Phenytoin can increase the effectiveness of oral contraceptives.

Correct answer: B

Rationale: The correct answer is B. Phenytoin can decrease the effectiveness of oral contraceptives, so it is important to inform the client about this interaction. Using an additional form of contraception, such as a backup method, is recommended to ensure adequate protection against pregnancy. Choice A is incorrect because it lacks specificity about the decrease in effectiveness of oral contraceptives caused by phenytoin. Choice C is incorrect as it suggests stopping phenytoin use while using oral contraceptives, which is not the appropriate action. Choice D is incorrect as phenytoin is known to decrease, not increase, the effectiveness of oral contraceptives.

3. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following sites should the healthcare provider select?

• A. Deltoid
• B. Vastus lateralis
• C. Rectus femoris
• D. Dorsogluteal

Correct answer: B

Rationale: The vastus lateralis is the preferred site for intramuscular injections in adults due to its large muscle mass and low risk of complications. The deltoid, although a common site for vaccines, has a smaller muscle mass and may not be suitable for all types of medications. The rectus femoris is a muscle in the thigh that is more commonly used for intramuscular injections in infants. The dorsogluteal site is no longer recommended due to its proximity to major nerves and blood vessels.

4. A nurse is providing teaching about digoxin administration to the parents of a toddler with heart failure. Which of the following statements should the nurse include?

• A. Limit your child's potassium intake while taking this medication.
• B. You can mix the medication with a half-cup of your child's favorite juice.
• C. Do not repeat the dose if your child vomits within one hour after taking the medication.
• D. Have your child drink a small glass of water after swallowing the medication.

Correct answer: D

Rationale: The correct statement to include in the teaching about digoxin administration is to have the child drink a small glass of water after swallowing the medication. Water helps flush down the medication, preventing irritation in the esophagus. Choice A is incorrect because digoxin may interact with potassium levels, but strict restriction is not necessary. Choice B is incorrect as medications should not be mixed with juices unless specified by the healthcare provider due to possible interactions. Choice C is incorrect because if a child vomits after taking digoxin, the dose should not be repeated to avoid double dosing.

5. A nurse is planning care for a client who is postoperative following a bowel resection. Which of the following interventions should the nurse include?

• A. Encourage the client to drink adequate fluids daily.
• B. Administer pain medication as needed.
• C. Instruct the client to splint the incision with a pillow.
• D. Encourage the client to eat a balanced diet.

Correct answer: C

Rationale: The correct intervention for a client post-bowel resection is to instruct the client to splint the incision with a pillow. This technique helps prevent dehiscence, which is the separation of wound edges, and reduces pain when coughing or moving. Splinting supports the incision site, decreasing tension on the wound. Encouraging the client to drink adequate fluids promotes hydration and aids in recovery, but a specific volume like 1,000 mL mentioned in choice A is not essential. Pain medication should be administered as needed for adequate pain control, not necessarily before every meal. Instructing the client to eat a balanced diet, including adequate protein, is crucial for wound healing and overall recovery, rather than limiting protein intake.

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