Nursing Elites

1. A client is in her third month of her first pregnancy. During the interview, she tells the nurse that she has several sex partners and is unsure of the identity of the baby's father. Which of the following nursing interventions is a priority?

• A. Counsel the woman to consent to HIV screening.
• B. Perform tests for sexually transmitted diseases.
• C. Discuss her high risk for cervical cancer.
• D. Refer the client to a family planning clinic.

Correct answer: A

Rationale: In this scenario, the client's disclosure of having multiple sex partners and uncertainty about the baby's father indicates a potential high risk for HIV. Therefore, the priority nursing intervention is to counsel the woman to consent to HIV screening. Early detection of HIV is crucial for initiating timely treatment and improving outcomes. Choices B, C, and D are not the priority in this situation as HIV screening takes precedence over testing for other sexually transmitted diseases, discussing cervical cancer risk, or referring to a family planning clinic.

2. The nurse reviews the record of a child who is suspected to have glomerulonephritis and expects to note which finding that is associated with this diagnosis?

• A. Hypotension
• B. Brown-colored urine
• C. Low urinary specific gravity
• D. Low blood urea nitrogen level

Correct answer: B

Rationale: Glomerulonephritis refers to a group of kidney disorders characterized by inflammatory injury in the glomerulus. Gross hematuria resulting in dark, smoky, cola-colored, or brown-colored urine is a classic symptom of glomerulonephritis. Hypertension is also common. Blood urea nitrogen levels may be elevated. A moderately elevated to high urinary specific gravity is associated with glomerulonephritis.

3. A client complained of nausea, a metallic taste in her mouth, and fine hand tremors 2 hours after her first dose of lithium carbonate (Lithane). What is the nurse's best explanation of these findings?

• A. These side effects are common and should subside in a few days.
• B. The client is probably having an allergic reaction and should discontinue the drug.
• C. Taking the lithium on an empty stomach should decrease these symptoms.
• D. Decreasing dietary intake of sodium and fluids should minimize the side effects.

Correct answer: A

Rationale: The correct answer is, 'These side effects are common and should subside in a few days.' Nausea, metallic taste, and fine hand tremors are common side effects of lithium carbonate (Lithane) and typically diminish within a few days as the body adjusts to the medication. Option B is incorrect because these symptoms are not indicative of an allergic reaction. Option C is incorrect as taking lithium on an empty stomach does not directly address or decrease these specific side effects. Option D is also incorrect as reducing sodium and fluid intake is not the recommended approach to managing these particular side effects of lithium.

4. A patient's chart indicates a history of hyperkalemia. Which of the following would you not expect to see with this patient if this condition were acute?

• A. Decreased HR
• B. Paresthesias
• C. Muscle weakness of the extremities
• D. Migraines

Correct answer: D

Rationale: The correct answer is 'Migraines.' Migraines are not a symptom typically associated with hyperkalemia. In acute hyperkalemia, one would not expect to see migraines. Symptoms of hyperkalemia often include muscle weakness, paresthesias, and cardiac manifestations such as bradycardia or even cardiac arrest. Therefore, choices A, B, and C are more commonly associated with acute hyperkalemia compared to migraines, making it the correct choice.

5. While auscultating a patient's lungs, the nurse hears low-pitched, bubbling sounds during inhalation in the lower third of both lungs. How should the nurse document this finding?

• A. Inspiratory crackles at the bases
• B. Expiratory wheezes in both lungs
• C. Abnormal lung sounds in the apices of both lungs
• D. Pleural friction rub in the right and left lower lobes

Correct answer: A

Rationale: The correct answer is 'Inspiratory crackles at the bases.' Crackles are low-pitched, bubbling sounds typically heard during inspiration, which aligns with the nurse's finding. Expiratory wheezes are high-pitched sounds and are not consistent with the described auscultation findings. The lower third of both lungs refers to the bases, not the apices, so option C is incorrect. Pleural friction rubs are grating sounds heard during both inspiration and expiration, unlike the described finding of only hearing the sounds during inhalation in the lower third of both lungs.

Similar Questions