Nursing Elites

1. A client is being taught how to use a diaphragm for contraception. Which of the following client statements indicate an understanding of the teaching?

• A. I will leave the diaphragm in place for at least 6 hours after intercourse.
• B. I will remove the diaphragm by catching the rim below the dome with my finger.
• C. I will not apply mineral oil on the diaphragm.
• D. I will place 2 teaspoons of spermicide on the inside of the diaphragm before inserting it.

Correct answer: D

Rationale: The correct answer is D. The client should place spermicide inside the diaphragm before insertion to enhance contraceptive effectiveness. It is recommended to leave the diaphragm in place for at least 6 hours after intercourse, but not more than 24 hours. Choice A is incorrect because the diaphragm should be left in place for at least 6 hours, not 4 hours. Choice B is incorrect as the diaphragm should be removed by hooking the rim below the dome, not above. Choice C is incorrect because mineral oil should not be used with the diaphragm as it can weaken the latex.

2. A nurse is planning to administer chlorothiazide 20 mg/kg/day PO divided equally and administered twice daily for a toddler who weighs 28.6 lb. How many mL should the nurse administer per dose? (Round to the nearest tenth)

• A. 2.6 mL
• B. 2.2 mL
• C. 3.5 mL
• D. 5.0 mL

Correct answer: A

Rationale: The correct calculation is as follows: The toddler's weight in kg is 13 kg (28.6 lb / 2.2 lb/kg). The total daily dose is 260 mg (20 mg x 13 kg). Therefore, the dose per administration is 130 mg (260 mg / 2). Given the concentration of 250 mg/5 mL, the dose in mL is 2.6 mL (130 mg / (250 mg/5 mL)). Therefore, the nurse should administer 2.6 mL per dose. Choice B, 2.2 mL, is incorrect as it does not reflect the correct calculation. Choices C and D, 3.5 mL and 5.0 mL, are also incorrect and do not align with the accurate dosage calculation based on the given scenario.

3. A nurse is assessing a client with pericarditis. Which of the following findings is the priority for the nurse to report?

• A. Paradoxical pulse
• B. Dependent edema
• C. Pericardial friction rub
• D. Substernal chest pain

Correct answer: A

Rationale: A paradoxical pulse is a sign of cardiac tamponade, a life-threatening complication of pericarditis that requires immediate intervention. It results from decreased cardiac output due to increased pressure in the pericardial sac. Reporting this finding promptly allows for timely treatment to prevent further deterioration. Dependent edema and substernal chest pain are common in pericarditis but are not as urgent as a paradoxical pulse. A pericardial friction rub is a classic finding in pericarditis and indicates inflammation but is not as critical as a paradoxical pulse.

4. A nurse is assessing a client for signs of deep vein thrombosis (DVT). Which of the following findings should the nurse look for?

• A. Swelling in the limb
• B. Decreased heart rate
• C. Increased appetite
• D. Improved mobility

Correct answer: A

Rationale: The correct answer is A: Swelling in the limb. Swelling, particularly in one limb, is a common sign of deep vein thrombosis (DVT) and should be assessed. This swelling is often accompanied by pain, redness, and warmth in the affected area. Choices B, C, and D are incorrect because decreased heart rate, increased appetite, and improved mobility are not typically associated with DVT. The main focus in assessing for DVT is recognizing the signs and symptoms related to venous thrombosis.

5. A client with a history of asthma is being cared for by a nurse. Which of the following should the nurse monitor?

• A. Heart rate
• B. Respiratory status
• C. Blood glucose levels
• D. Liver function

Correct answer: B

Rationale: The correct answer is B: Respiratory status. When caring for a client with asthma, it is essential to monitor their respiratory status to detect any changes in breathing or signs of airway obstruction. Monitoring heart rate (choice A) may be important in some situations but is not the priority when managing asthma. Blood glucose levels (choice C) and liver function (choice D) are not directly related to asthma and would not be the primary focus of monitoring for a client with this condition.

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