Nursing Elites

1. The nurse is assessing a primigravida at 39-weeks gestation during a weekly prenatal visit. Which finding is most important for the nurse to report to the healthcare provider?

• A. Fetal heart rate of 200 beats/minute.
• B. Mild ankle edema.
• C. Complaints of back pain.
• D. Decreased fetal movements.

Correct answer: A

Rationale: A fetal heart rate of 200 beats per minute is significantly elevated and requires immediate medical attention. This finding could indicate fetal distress, tachycardia, or other serious issues that need prompt evaluation. Mild ankle edema, complaints of back pain, and decreased fetal movements are common in pregnancy but are not as urgent or concerning as a high fetal heart rate.

2. A client with urticaria due to environmental allergies is taking diphenhydramine. Which complaint should the nurse identify as a side effect of the OTC medication?

• A. Nausea and indigestion.
• B. Hypersalivation.
• C. Eyelid and facial twitching.
• D. Increased appetite.

Correct answer: A

Rationale: The correct answer is A: Nausea and indigestion. Diphenhydramine, an antihistamine, commonly causes gastrointestinal side effects such as nausea and indigestion. This medication can have anticholinergic effects, leading to these symptoms. Choices B, C, and D are incorrect because hypersalivation, eyelid and facial twitching, and increased appetite are not typically associated with diphenhydramine use.

3. A client with newly diagnosed hypertension is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?

• A. ‘I will reduce my salt intake to help manage my blood pressure.’
• B. ‘I will start exercising regularly to help control my blood pressure.’
• C. ‘I will avoid drinking alcohol to help manage my blood pressure.’
• D. ‘I will limit my caffeine intake to help control my blood pressure.’

Correct answer: D

Rationale: The correct answer is D. Limiting caffeine intake is a positive lifestyle modification for managing hypertension. The statement indicates that the client understands the importance of reducing caffeine intake. Choices A, B, and C all reflect appropriate lifestyle modifications for managing hypertension, indicating good understanding by the client.

4. A client with peptic ulcer disease is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?

• A. ‘I should avoid drinking alcohol to prevent irritation of my ulcer.’
• B. ‘I should take my antacids regularly, even if I don’t have symptoms.’
• C. ‘I should avoid eating spicy foods to prevent irritation of my ulcer.’
• D. ‘I should limit my caffeine intake to prevent irritation of my ulcer.’

Correct answer: B

Rationale: The statement ‘I should take my antacids regularly, even if I don’t have symptoms’ indicates a misunderstanding. Antacids should only be taken when symptoms are present to neutralize excess stomach acid. Taking antacids regularly when not experiencing symptoms may lead to metabolic alkalosis. Choices A, C, and D are correct statements for a client with peptic ulcer disease as they all focus on avoiding irritants that can exacerbate the condition.

5. A client with hypertension receives a prescription for enalapril, an angiotensin-converting enzyme (ACE) inhibitor. Which instruction should the nurse include in the medication teaching plan?

• A. Increase intake of potassium-rich foods.
• B. Report increased bruising or bleeding.
• C. Stop medication if a cough develops.
• D. Limit intake of leafy green vegetables.

Correct answer: B

Rationale: The correct instruction for the nurse to include in the medication teaching plan is to 'Report increased bruising or bleeding.' ACE inhibitors can cause thrombocytopenia, which lowers platelet count and increases the risk of bruising and bleeding. Choice A is incorrect because while ACE inhibitors may cause potassium levels to increase, the instruction should not be to increase intake of potassium-rich foods without healthcare provider guidance. Choice C is incorrect because a cough is a common side effect of ACE inhibitors due to bradykinin accumulation, and stopping the medication abruptly is not recommended without consulting the healthcare provider. Choice D is incorrect because there is no need to limit intake of leafy green vegetables specifically with ACE inhibitors; however, consistent intake of vitamin K-rich foods is recommended to maintain a stable INR for clients taking anticoagulants.

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