Nursing Elites

1. What physical assessment data should the nurse consider a normal finding for a primigravida client who is 12 hours postpartum?

• A. Soft, spongy fundus.
• B. Saturating two perineal pads per hour.
• C. Pulse rate of 56 BPM.
• D. Unilateral lower leg pain.

Correct answer: C

Rationale: The correct answer is C. A pulse rate of 56 BPM can be considered a normal finding for a primigravida client who is 12 hours postpartum. Postpartum bradycardia can occur due to increased stroke volume and decreased vascular resistance after delivery. It is important for the nurse to monitor the client's vital signs and recognize that a lower pulse rate can be expected in the immediate postpartum period. Choices A, B, and D are incorrect because a soft, spongy fundus may indicate uterine atony, saturating two perineal pads per hour is excessive bleeding, and unilateral lower leg pain could suggest deep vein thrombosis, all of which would require further assessment and intervention.

2. The healthcare professional is caring for a client with heart failure who is receiving digoxin (Lanoxin). Which assessment finding requires immediate intervention?

• A. Heart rate of 58 beats per minute.
• B. Nausea and vomiting.
• C. Blood pressure of 130/80 mm Hg.
• D. Shortness of breath.

Correct answer: B

Rationale: The correct answer is B. Nausea and vomiting are common signs of digoxin toxicity, which can lead to serious complications like dysrhythmias. Prompt intervention is crucial to prevent further harm to the client. Choice A, a heart rate of 58 beats per minute, although slightly lower than normal, may be appropriate for a client on digoxin. Choice C, a blood pressure of 130/80 mm Hg, is within normal limits and does not indicate an immediate need for intervention. Choice D, shortness of breath, is a common symptom in heart failure and requires monitoring but is not as indicative of digoxin toxicity as nausea and vomiting.

3. A client with heart failure is prescribed digoxin (Lanoxin). Which instruction should the nurse include in the client's teaching plan?

• A. Take your pulse before each dose and hold the medication if your pulse is below 60 beats per minute.
• B. Increase your intake of foods high in potassium.
• C. Take the medication with a high-fiber meal to enhance absorption.
• D. Skip a dose if you feel dizzy or lightheaded.

Correct answer: A

Rationale: The correct instruction for a client prescribed digoxin is to take their pulse before each dose and hold the medication if the pulse is below 60 beats per minute. This is crucial to prevent digoxin toxicity, as digoxin can cause adverse effects when the pulse rate is too low. Monitoring the pulse regularly ensures safety and appropriate management of the medication.

4. A client with a history of asthma is prescribed salmeterol (Serevent). Which instruction should the nurse provide?

• A. Use this medication for acute asthma attacks.
• B. Use this medication before using your albuterol inhaler.
• C. Use this medication twice daily for long-term control.
• D. Use this medication as needed for wheezing.

Correct answer: C

Rationale: The correct instruction for a client prescribed salmeterol (Serevent) is to use it twice daily for long-term control. Salmeterol is a long-acting bronchodilator that is not intended for acute asthma attacks or as-needed use for wheezing. Choice A is incorrect because salmeterol is not used for acute asthma attacks. Choice B is incorrect as salmeterol is not meant to replace the albuterol inhaler but rather used for long-term control. Choice D is incorrect because salmeterol should not be used as needed; it is a maintenance medication for asthma.

5. A 55-year-old man presents with jaundice, pruritus, and dark urine. Laboratory tests reveal elevated bilirubin and alkaline phosphatase. Imaging shows dilated intrahepatic bile ducts and a normal common bile duct. What is the most likely diagnosis?

• A. Primary biliary cirrhosis
• B. Primary sclerosing cholangitis
• C. Gallstones
• D. Pancreatic cancer

Correct answer: A

Rationale: The clinical presentation of jaundice, pruritus, dark urine, elevated bilirubin and alkaline phosphatase, along with imaging findings of dilated intrahepatic bile ducts and a normal common bile duct, are characteristic of primary biliary cirrhosis. Primary biliary cirrhosis is an autoimmune liver disease that leads to destruction of intrahepatic bile ducts, causing cholestasis and liver damage. This condition typically presents in middle-aged women but can also affect men, as seen in this case.

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