Nursing Elites

1. A nurse is caring for a client who has a new prescription for an antidepressant. The client reports experiencing dry mouth. Which of the following instructions should the nurse give the client?

• A. Decrease fluid intake.
• B. Chew sugarless gum.
• C. Avoid using mouthwash.
• D. Increase intake of dairy products.

Correct answer: B

Rationale: The correct answer is to instruct the client to chew sugarless gum. Chewing sugarless gum can help alleviate dry mouth by stimulating saliva production, which is a common side effect of many antidepressants. Decreasing fluid intake (choice A) is not recommended as it can worsen dry mouth. Avoiding mouthwash (choice C) is not as effective as chewing gum in stimulating saliva. Increasing intake of dairy products (choice D) is not directly related to managing dry mouth caused by antidepressants.

2. A community health nurse is teaching a group of clients about first aid for different types of wounds. Which of the following client statements indicates an understanding of the teaching?

• A. I should apply clean dressings over blood-saturated dressings and hold pressure.
• B. I will rinse the wound with hot water to cleanse it.
• C. I can remove the dressing once the bleeding stops.
• D. I should apply antibiotic ointment directly to the wound.

Correct answer: A

Rationale: The correct answer is A because applying clean dressings over blood-saturated dressings and holding pressure helps prevent disruption of wound tissue, aiding in the clotting process and controlling bleeding. Choice B is incorrect as rinsing a wound with hot water can cause further tissue damage. Choice C is incorrect as the dressing should not be removed once applied as it can disrupt the formation of a clot. Choice D is incorrect as antibiotic ointment should not be applied directly to the wound during initial first aid.

3. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post-maturity
• D. Head compression

Correct answer: D

Rationale: When early decelerations are noted on the fetal monitor tracing, it indicates fetal head compression, which is typically a benign finding associated with the progress of labor. Early decelerations mirror the uterine contractions and are often not a cause for concern as they are a normal response to fetal head compression during contractions. Choices A, B, and C are incorrect as they do not align with the expected outcome of early decelerations. Fetal hypoxia, abruptio placentae, and post-maturity would present with different patterns on the fetal monitor tracing and would require different interventions.

4. A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?

• A. Lower back pain
• B. Shortness of breath
• C. Decreased fetal movement
• D. Nausea and vomiting

Correct answer: A

Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery. Shortness of breath (Choice B), decreased fetal movement (Choice C), and nausea and vomiting (Choice D) can be common during pregnancy but are not typically associated with preterm labor. While they should be monitored, they are not immediate signs of concern for preterm labor.

5. A nurse is caring for a 7-month-old infant being treated for severe dehydration. Which finding indicates treatment has been effective?

• A. Skin turgor displays tenting
• B. Flat anterior fontanel
• C. Cool, mottled skin
• D. Hyperpnea

Correct answer: B

Rationale: A flat anterior fontanel indicates improved hydration in infants, as dehydration typically causes sunken fontanels.

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