Nursing Elites

1. A nurse is caring for a client who has severe preeclampsia. Which of the following interventions should the nurse include in the plan of care?

• A. Administer magnesium sulfate.
• B. Place the client in the left lateral position.
• C. Monitor intake and output.
• D. Provide a low-sodium diet.

Correct answer: C

Rationale: The correct intervention for a client with severe preeclampsia is to monitor intake and output. This is crucial to assess kidney function, fluid balance, and detect any signs of deterioration. Administering magnesium sulfate is indicated for seizure prophylaxis in severe preeclampsia, but it is not the primary intervention related to care planning. Placing the client in the left lateral position is not a specific intervention for managing preeclampsia. Providing a low-sodium diet is not typically recommended for clients with severe preeclampsia as sodium restriction is not a primary treatment modality for this condition.

2. A client, 12 hours postpartum, reports not having a bowel movement for 4 days. Which medication should the nurse administer?

• A. Bisacodyl 10 mg rectal suppository.
• B. Magnesium hydroxide 30 ml PO.
• C. Famotidine 20 mg PO.
• D. Loperamide 4 mg PO.

Correct answer: A

Rationale: In this scenario, the nurse should administer Bisacodyl 10 mg rectal suppository. The client's report of not having a bowel movement for 4 days indicates constipation, and Bisacodyl is a stimulant laxative that helps initiate bowel movements. Magnesium hydroxide is an antacid and osmotic laxative used for indigestion, not for constipation. Famotidine is an H2 receptor antagonist used to reduce stomach acid production and treat heartburn, not constipation. Loperamide is an antidiarrheal agent and would be contraindicated in a client experiencing constipation.

3. A nurse is preparing to administer an intermittent enteral feeding to a client who has an NG tube. Which of the following actions should the nurse take?

• A. Heat the feeding to 105°F (40.6°C).
• B. Elevate the head of the bed to 45 degrees.
• C. Flush the tube with 0.9% sodium chloride.
• D. Verify the pH of the gastric aspirate.

Correct answer: D

Rationale: Verifying the pH of the gastric aspirate is the correct action to take before administering an intermittent enteral feeding through an NG tube. This step ensures proper tube placement in the stomach, as the gastric aspirate should have an acidic pH (usually below 5). Heating the feeding solution, elevating the head of the bed, or flushing the tube with saline are not directly related to verifying tube placement and are not the immediate actions needed before administering the feeding.

4. A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

• A. Abdominal cramps
• B. Irritability
• C. Increased thirst
• D. Blurred vision

Correct answer: B

Rationale: Irritability is a common early manifestation of hypoglycemia. When blood glucose levels drop, the brain perceives this as a stressor, leading to irritability. Abdominal cramps (choice A) are not typically associated with hypoglycemia but can occur with other gastrointestinal issues. Increased thirst (choice C) is more indicative of hyperglycemia rather than hypoglycemia. Blurred vision (choice D) is a symptom more commonly associated with hyperglycemia rather than hypoglycemia.

5. A healthcare provider is assessing a client who has acute pancreatitis. Which of the following laboratory results should the healthcare provider expect to be elevated?

• A. Serum sodium.
• B. Serum calcium.
• C. Serum glucose.
• D. Serum amylase.

Correct answer: D

Rationale: Serum amylase levels are typically elevated in clients with acute pancreatitis as it is an enzyme released by the pancreas. Elevated serum sodium, calcium, or glucose levels are not typically associated with acute pancreatitis. Therefore, choices A, B, and C are incorrect.

Similar Questions