Nursing Elites

1. A client who is at 12 weeks of gestation and has hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory values should the nurse report to the provider?

• A. Sodium 140 mEq/L
• B. Potassium 3.8 mEq/L
• C. Blood glucose 90 mg/dL
• D. Urine ketones present

Correct answer: D

Rationale: The correct answer is D: Urine ketones present. The presence of urine ketones indicates dehydration and inadequate glucose control in clients with hyperemesis gravidarum. Reporting this finding to the provider is crucial for prompt intervention to prevent further complications. Choices A, B, and C are within normal ranges and do not directly correlate with the condition of hyperemesis gravidarum. Therefore, they are not the priority values to report in this scenario.

2. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Redness and warmth in the calf
• C. Oxygen saturation of 95%
• D. Temperature of 37.3°C (99.1°F)

Correct answer: B

Rationale: Redness and warmth in the calf can indicate a blood clot, specifically deep vein thrombosis (DVT), which is a serious complication post hip arthroplasty. The warmth and redness are signs of inflammation due to the clot formation. DVT can lead to a pulmonary embolism if not addressed promptly. Monitoring for this complication is crucial in postoperative care. Elevated heart rate, oxygen saturation within normal limits, and a slightly elevated temperature are common findings postoperatively and may not be alarming in the absence of other concerning symptoms.

3. A client is receiving opioid analgesics for pain management. Which of the following assessments is the priority?

• A. Monitor the client's blood pressure.
• B. Check the client's urinary output.
• C. Monitor the client's respiratory rate.
• D. Assess the client's pain level.

Correct answer: C

Rationale: The correct answer is C: Monitor the client's respiratory rate. When a client is receiving opioid analgesics, the priority assessment is monitoring respiratory rate. Opioids can cause respiratory depression, so it is crucial to assess the client's breathing to detect any signs of respiratory distress promptly. Checking the client's blood pressure (Choice A) and urinary output (Choice B) are important assessments too, but they are not the priority when compared to ensuring adequate respiratory function. Assessing the client's pain level (Choice D) is essential for overall care but is not the priority assessment when the client is on opioids, as respiratory status takes precedence.

4. A nurse is providing dietary teaching to a client with irritable bowel syndrome (IBS). What recommendation should be included?

• A. Consume foods high in bran fiber.
• B. Increase intake of milk products.
• C. Sweeten foods with fructose corn syrup.
• D. Increase intake of foods high in gluten.

Correct answer: A

Rationale: The correct answer is A: Consume foods high in bran fiber. Bran fiber is recommended for clients with IBS as it promotes regularity and helps reduce symptoms. Choices B, C, and D are incorrect. Increasing milk products may exacerbate symptoms in some individuals with IBS due to lactose intolerance. Sweetening foods with fructose corn syrup can worsen symptoms as it is a type of sugar that can lead to gastrointestinal discomfort. Increasing intake of foods high in gluten is not recommended for individuals with IBS, especially those with gluten sensitivity, as it may trigger or worsen symptoms.

5. While reviewing the monitor tracing of a client in labor, a nurse notes late decelerations. Which of the following interventions should the nurse perform?

• A. Administer oxygen via nasal cannula
• B. Reposition the client onto her left side
• C. Administer an amnioinfusion
• D. Provide reassurance to the client

Correct answer: B

Rationale: Repositioning the client onto her left side is the appropriate intervention when late decelerations are noted on the monitor tracing. This action helps increase uteroplacental blood flow by relieving pressure on the vena cava and aorta, improving fetal oxygenation. Administering oxygen via nasal cannula may be indicated for variable decelerations, not late decelerations. Administering an amnioinfusion is not the primary intervention for late decelerations. Providing reassurance to the client is important but addressing the underlying cause of late decelerations takes precedence.

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