Nursing Elites

1. In a client in her third trimester of pregnancy, an S3 heart sound is auscultated. What intervention should the nurse take?

• A. Notify the healthcare provider
• B. Limit the client’s fluids
• C. Prepare the client for an echocardiogram
• D. Document in the client’s record

Correct answer: D

Rationale: An S3 heart sound can be a normal finding in pregnancy due to increased blood volume and flow. In this scenario, there is no immediate need for further interventions. Documenting this finding in the client's record is essential for tracking the client's health status and ensuring proper follow-up if needed. Notifying the healthcare provider, limiting fluids, or preparing for an echocardiogram is unnecessary as it is likely a physiological finding in pregnancy. These interventions should only be considered if other symptoms suggestive of a cardiac issue are present.

2. The parents of a 6-year-old recently diagnosed with asthma should be taught that the symptom of acute episodes of asthma is due to which physiological response?

• A. Inflammation of the mucous membrane & bronchospasm
• B. Increased mucus production and bronchoconstriction
• C. Allergic reactions and hyperventilation
• D. Airway narrowing and decreased lung capacity

Correct answer: A

Rationale: The correct answer is A: Inflammation of the mucous membrane & bronchospasm. Acute asthma episodes are primarily caused by inflammation of the airways and bronchospasm, which lead to airway obstruction. Increased mucus production and bronchoconstriction (Choice B) are part of the physiological responses in asthma but do not directly cause acute episodes. Allergic reactions and hyperventilation (Choice C) are related to asthma triggers and responses but are not the direct causes of acute episodes. Airway narrowing and decreased lung capacity (Choice D) are consequences of inflammation and bronchospasm but do not explain the physiological response leading to acute asthma episodes.

3. What information is most important for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia?

• A. Ensure the partner is screened for chlamydia
• B. Report any signs of liver dysfunction immediately
• C. Avoid consuming grapefruit juice while on this medication
• D. Use two forms of contraception while taking this drug

Correct answer: D

Rationale: The most important information for the nurse to provide to an adolescent female prescribed azithromycin for lower lobe pneumonia and recurrent chlamydia is to use two forms of contraception while taking this drug. Azithromycin can reduce the effectiveness of hormonal contraceptives, increasing the risk of pregnancy. It is crucial to convey this information to prevent unintended pregnancies. Option A is incorrect as the partner should be screened for chlamydia, not HIV, in this case. Option B is not the most important information to provide as liver dysfunction is a rare side effect of azithromycin. Option C is irrelevant as grapefruit juice does not interact with azithromycin. Therefore, the priority information to convey is the importance of using dual contraception to prevent pregnancy.

4. A client recovering from abdominal surgery is on a clear liquid diet. The nurse should identify which of the following as the most appropriate food choice for this diet?

• A. Chicken noodle soup
• B. Grape juice
• C. Cream of wheat
• D. Vanilla pudding

Correct answer: B

Rationale: Grape juice is the most appropriate choice for a clear liquid diet as it is a transparent fluid that is easily digested. Clear liquid diets aim to provide fluids and electrolytes while being easy on the digestive system. Choices A, C, and D are not suitable for a clear liquid diet as they are not in liquid form or do not meet the criteria of being easily digestible for someone recovering from abdominal surgery. Chicken noodle soup, cream of wheat, and vanilla pudding are not considered clear liquids and may not be well-tolerated by a client who has undergone abdominal surgery.

5. A 41-week gestation primigravida woman is admitted to labor and delivery for induction of labor. What finding should the nurse report to the healthcare provider before initiating the infusion of oxytocin?

• A. Fetal heart tones located in the upper right quadrant
• B. Biophysical profile results showing oligohydramnios
• C. Regular contractions occurring every 10 minutes
• D. Sterile vaginal exam revealing 3 cm dilation

Correct answer: B

Rationale: Oligohydramnios (low amniotic fluid) is a significant concern before starting oxytocin and should be reported to ensure safe labor induction. This finding can indicate potential fetal compromise and requires immediate evaluation. Fetal heart tones located in a specific quadrant, regular contractions, and cervical dilation are common assessments during labor but are not as critical as oligohydramnios in this scenario.

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