Nursing Elites

1. A nurse is assessing a client who is experiencing a panic attack. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Hypotension.
• C. Chest pain.
• D. Dilated pupils.

Correct answer: D

Rationale: During a panic attack, the sympathetic nervous system is activated, leading to physiological responses such as dilated pupils. Bradycardia (slow heart rate) and hypotension (low blood pressure) are not typically associated with panic attacks. While chest pain can occur during a panic attack due to rapid breathing and muscle tension, dilated pupils are a more specific finding related to sympathetic activation in this context.

2. A nurse is teaching a client who has a new prescription for iron supplements. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication with a glass of milk.
• B. I will take this medication with orange juice.
• C. I should expect my stools to be black and tarry.
• D. I will take this medication before bedtime.

Correct answer: C

Rationale: The correct answer is C. When a client understands the teaching about iron supplements, they should know that black, tarry stools are a normal side effect. This indicates that the medication is being absorbed and working effectively. Choices A and B are incorrect because iron supplements should not be taken with milk or orange juice, as these can interfere with the absorption of iron. Choice D is also incorrect because iron supplements are usually best absorbed on an empty stomach, so taking them before bedtime may not be ideal.

3. 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.

4. A nurse is caring for a client who has chronic kidney disease and is experiencing fluid volume overload. Which of the following findings should the nurse expect?

• A. Decreased blood pressure
• B. Increased urine output
• C. Decreased heart rate
• D. Increased heart rate

Correct answer: A

Rationale: In a client with chronic kidney disease experiencing fluid volume overload, the nurse should expect a decreased blood pressure. Fluid volume overload can lead to poor cardiac output, which in turn can cause a decrease in blood pressure. Choices B, C, and D are incorrect. Increased urine output is not expected in fluid volume overload; decreased heart rate is not typically associated with fluid volume overload; and an increased heart rate is more commonly seen in response to fluid overload to compensate for the decreased cardiac output.

5. A nurse is preparing to insert an indwelling urinary catheter for a male client. Which of the following actions should the nurse take?

• A. Insert the catheter until urine flows, then advance 2.5 to 5 cm (1 to 2 in) further.
• B. Advance the catheter 7.5 to 10 cm (3 to 4 in) after urine begins to flow.
• C. Advance the catheter 17 to 22.5 cm (7 to 9 in) after urine begins to flow.
• D. Advance the catheter 5 to 7.5 cm (2 to 3 in) after urine begins to flow.

Correct answer: C

Rationale: When inserting an indwelling urinary catheter for a male client, it is crucial to advance the catheter 17 to 22.5 cm after urine begins to flow. This helps ensure proper placement in the male urethra, which is longer compared to females. Choice A is incorrect as advancing only 2.5 to 5 cm would not reach the correct placement in male clients. Choice B is incorrect as advancing 7.5 to 10 cm is insufficient to reach the appropriate location in male clients. Choice D is also incorrect as advancing 5 to 7.5 cm would likely not reach the desired placement in male clients.

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