Nursing Elites

1. Which of the following interventions is most appropriate for a client with hyperemesis gravidarum?

• A. Encourage high-calorie meals
• B. Administer intravenous fluids
• C. Provide frequent small meals
• D. Limit fluid intake

Correct answer: B

Rationale: The correct answer is B: Administer intravenous fluids. Hyperemesis gravidarum is severe, persistent nausea and vomiting during pregnancy that can lead to dehydration and electrolyte imbalances. The priority intervention is to administer intravenous fluids to maintain hydration. Encouraging high-calorie meals (Choice A) may exacerbate symptoms due to increased gastric stimulation. Providing frequent small meals (Choice C) may not be effective in severe cases where continuous vomiting occurs. Limiting fluid intake (Choice D) is contraindicated in hyperemesis gravidarum as dehydration is a significant concern.

2. A nurse is preparing to perform a routine abdominal assessment for a client. Which action should the nurse take?

• A. Perform palpation before auscultation
• B. Perform percussion before auscultation
• C. Perform palpation after auscultation
• D. Perform inspection after auscultation

Correct answer: C

Rationale: The correct answer is C: Perform palpation after auscultation. When conducting an abdominal assessment, the correct sequence is inspection, auscultation, percussion, and then palpation. Inspecting the abdomen allows the nurse to observe any visible abnormalities, followed by listening for bowel sounds during auscultation. Percussion helps assess the density of abdominal contents before palpation for tenderness, masses, or organ enlargement. Choices A, B, and D are incorrect because palpation should always come last in the sequence of an abdominal assessment.

3. A nurse is assessing a client with suspected myocardial infarction. Which finding supports this diagnosis?

• A. Pain radiating to the left arm
• B. Pain relieved by rest
• C. Pain worsening with deep breathing
• D. Pain relieved by antacids

Correct answer: A

Rationale: The correct answer is A. Pain radiating to the left arm is a classic symptom of myocardial infarction, commonly known as a heart attack. This occurs due to the referred pain pathways shared by the heart and the left arm. Choices B, C, and D are incorrect. Pain relieved by rest (choice B) is more indicative of musculoskeletal pain rather than cardiac-related pain. Pain worsening with deep breathing (choice C) is often seen in conditions like pleurisy or pulmonary embolism, not myocardial infarction. Pain relieved by antacids (choice D) suggests gastrointestinal issues like heartburn or acid reflux, not cardiac-related pain.

4. A nurse is caring for a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the healthcare provider?

• A. Urinary output of 40 mL/hr
• B. Respiratory rate of 10 breaths per minute
• C. Absent deep tendon reflexes
• D. Blood pressure of 150/90 mm Hg

Correct answer: B

Rationale: Magnesium sulfate can depress the central nervous system, leading to respiratory depression. A respiratory rate of 10 breaths per minute is below the normal range and requires immediate intervention. Urinary output of 40 mL/hr (Choice A) is within the normal range for a client receiving magnesium sulfate. Absent deep tendon reflexes (Choice C) are an expected finding due to the medication's effect on neuromuscular excitability. A blood pressure of 150/90 mm Hg (Choice D) is slightly elevated but not a priority concern compared to severe respiratory depression.

5. A nurse is assessing a client who is receiving chemotherapy and has stomatitis. Which of the following findings should the nurse expect?

• A. Dry, cracked lips
• B. Bleeding gums
• C. Foul-smelling breath
• D. Red, open sores in the mouth

Correct answer: D

Rationale: The correct answer is D: Red, open sores in the mouth. Stomatitis, a common side effect of chemotherapy, presents with red, open sores in the mouth, which can be painful and increase the risk of infection. Choices A, B, and C are incorrect because stomatitis typically does not manifest as dry, cracked lips, bleeding gums, or foul-smelling breath.

Similar Questions