Nursing Elites

1. A client is prescribed spironolactone. Which of the following dietary instructions should the nurse include?

• A. Increase potassium-rich foods
• B. Limit sodium intake
• C. Avoid potassium supplements
• D. Increase protein intake

Correct answer: C

Rationale: The correct answer is to advise the client to avoid potassium supplements. Spironolactone is a potassium-sparing diuretic, meaning it helps the body retain potassium. Adding potassium supplements on top of this medication can lead to hyperkalemia, an elevated level of potassium in the blood, which can be dangerous. Choices A, B, and D are incorrect because increasing potassium-rich foods, limiting sodium intake, and increasing protein intake are not specifically related to the dietary considerations when taking spironolactone.

2. A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?

• A. Redness at the site
• B. Warmth around the site
• C. Edema
• D. Pain at the site

Correct answer: C

Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration. Redness, warmth, and pain at the site are more indicative of phlebitis, not infiltration. Phlebitis is characterized by redness, warmth, and pain along the vein where the IV is placed, while infiltration involves the leaking of IV fluids into the surrounding tissue.

3. A healthcare professional is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare professional use?

• A. Numeric rating scale
• B. Behavioral indicators
• C. Visual analog scale
• D. Faces pain scale

Correct answer: B

Rationale: For clients with dementia who have difficulty communicating, assessing pain using behavioral indicators like increased agitation and restlessness is more effective than relying on self-reported scales such as numeric rating scale, visual analog scale, or faces pain scale. Behavioral indicators provide valuable insights into pain perception in individuals who may have challenges expressing themselves verbally.

4. A nurse is assessing a 1-hour postpartum client and notes a boggy uterus located 2 cm above the umbilicus. Which of the following actions should the nurse take first?

• A. Take vital signs
• B. Assess lochia
• C. Massage the fundus
• D. Give oxytocin IV bolus

Correct answer: C

Rationale: When a nurse assesses a 1-hour postpartum client with a boggy uterus located 2 cm above the umbilicus, it indicates uterine atony. The first action the nurse should take is to massage the fundus. Fundal massage helps stimulate uterine contractions, which will reduce bleeding and prevent postpartum hemorrhage. Taking vital signs, assessing lochia, or administering an oxytocin IV bolus are important interventions but should come after addressing uterine atony through fundal massage.

5. A nurse is providing education to a client in the first trimester of pregnancy. What information should the nurse include regarding the cause of indigestion and heartburn?

• A. Estrogen causes increased appetite
• B. Progesterone causes relaxation of the cardiac sphincter allowing acid to reflux
• C. HCG hormone leads to increased gastric acidity
• D. The uterus compresses the stomach early in pregnancy

Correct answer: B

Rationale: The correct answer is B. Progesterone causes relaxation of the smooth muscles in the body, including the cardiac sphincter. This relaxation allows stomach acid to reflux into the esophagus, leading to heartburn during pregnancy. Choices A, C, and D are incorrect because they do not directly relate to the physiological mechanism that causes heartburn during pregnancy. Estrogen causing increased appetite (Choice A) is not directly linked to heartburn. HCG hormone increasing gastric acidity (Choice C) is not the primary cause of heartburn during pregnancy. The uterus compressing the stomach early in pregnancy (Choice D) may contribute to feelings of fullness or bloating but is not the main cause of heartburn.

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