Nursing Elites

1. A nurse is assessing a client who is at 34 weeks of gestation and has gestational hypertension. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 140/90 mm Hg
• B. Fasting blood glucose of 120 mg/dL
• C. Urinary output of 40 mL/hr
• D. Weight gain of 2.3 kg (5 lb) in 1 week

Correct answer: D

Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening gestational hypertension and should be reported to the provider. Sudden weight gain in a client with gestational hypertension can be a sign of fluid retention, which could worsen the hypertension and lead to complications like preeclampsia. The other options, blood pressure of 140/90 mm Hg, fasting blood glucose of 120 mg/dL, and urinary output of 40 mL/hr, are within normal limits for a client with gestational hypertension and do not pose an immediate concern that requires reporting to the provider.

2. A client is receiving discharge teaching for a new prescription of digoxin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will stop taking this medication if my heart rate is below 80/min.
• B. I should take my pulse before taking this medication.
• C. I should stop taking this medication if my pulse is above 100/min.
• D. I will take this medication with an antacid.

Correct answer: B

Rationale: The correct answer is B. Clients taking digoxin should check their pulse before each dose to ensure it is within the appropriate range. Option A is incorrect because stopping the medication based solely on a heart rate below 80/min is not recommended. Option C is incorrect as having a pulse above 100/min doesn't necessarily indicate a need to stop digoxin. Option D is incorrect because digoxin should not be taken with an antacid as it can interfere with its absorption.

3. A client is 2 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?

• A. Position the client supine with a pillow between the legs.
• B. Place an abduction pillow between the client's legs.
• C. Place a pillow under the client's knees.
• D. Position the client's legs in adduction.

Correct answer: B

Rationale: After a total hip arthroplasty, it is crucial to prevent hip dislocation. Placing an abduction pillow between the client's legs helps maintain proper alignment of the hip joint and prevents adduction, which could lead to dislocation. Therefore, choice B is the correct action. Choice A is incorrect because positioning the client supine with a pillow between the legs does not provide the necessary abduction to prevent dislocation. Choice C, placing a pillow under the client's knees, does not address the need for abduction. Choice D, positioning the client's legs in adduction, is incorrect as adduction increases the risk of hip dislocation following hip arthroplasty.

4. A client has a new prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take this medication with food to prevent nausea.
• B. Notify your provider if you experience visual disturbances.
• C. Take an antacid with this medication if indigestion occurs.
• D. Avoid taking this medication if your heart rate is less than 60/min.

Correct answer: B

Rationale: The correct instruction for a client taking digoxin is to notify their provider if they experience visual disturbances. Visual disturbances can be a sign of digoxin toxicity, and prompt notification to the healthcare provider is essential for timely intervention. Choice A is incorrect because digoxin should be taken on an empty stomach for better absorption. Choice C is incorrect because antacids can interfere with the absorption of digoxin. Choice D is incorrect because a heart rate less than 60/min is not a sole reason to avoid taking digoxin; rather, it is important to monitor the heart rate and consult with the healthcare provider if there are concerns.

5. A client at 10 weeks of gestation reports frequent nausea and vomiting. Which of the following instructions should the nurse include?

• A. Eat high-protein foods.
• B. Lie down after meals.
• C. Drink water with meals.
• D. Eat dry carbohydrates before getting out of bed.

Correct answer: D

Rationale: During early pregnancy, nausea and vomiting are common. Instructing the client to eat dry carbohydrates like crackers before getting out of bed can help alleviate these symptoms. This recommendation helps prevent an empty stomach, which can worsen nausea. High-protein foods (Choice A) may be harder to digest and could exacerbate nausea. Lying down after meals (Choice B) may increase gastric reflux and worsen symptoms. Drinking water with meals (Choice C) may make the client feel fuller, potentially worsening nausea.

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