Nursing Elites

1. A nurse is caring for a client who is at 33 weeks of gestation following an amniocentesis. The nurse should monitor the client for which of the following complications?

• A. Vomiting.
• B. Hypertension.
• C. Epigastric pain.
• D. Contractions.

Correct answer: D

Rationale: Following an amniocentesis at 33 weeks of gestation, the nurse should monitor the client for contractions. Contractions can indicate preterm labor, which requires immediate attention. Vomiting, hypertension, and epigastric pain are not typically associated with amniocentesis complications at this gestational age.

2. A nurse is planning care for a client who is receiving hemodialysis. Which of the following actions should the nurse include in the plan of care?

• A. Withhold all medications until after dialysis.
• B. Rehydrate with dextrose 5% in water for orthostatic hypotension.
• C. Check the vascular access site for bleeding after dialysis.
• D. Give an antibiotic 30 minutes before dialysis.

Correct answer: C

Rationale: The correct action the nurse should include in the plan of care for a client receiving hemodialysis is to check the vascular access site for bleeding after dialysis. This is crucial to detect any bleeding complications and ensure prompt intervention if necessary. Withholding all medications until after dialysis (Choice A) is not appropriate as some medications may need to be administered during dialysis. Rehydrating with dextrose 5% in water for orthostatic hypotension (Choice B) is not directly related to the immediate post-dialysis care. Giving an antibiotic 30 minutes before dialysis (Choice D) is not recommended as timing of medication administration should be based on the specific antibiotic and its pharmacokinetics.

3. A healthcare professional is preparing to administer packed red blood cells (PRBCs) to a client. Which of the following actions should the healthcare professional take?

• A. Infuse the PRBCs over 8 hours.
• B. Verify the client's blood type and Rh factor.
• C. Administer the PRBCs through a 24-gauge catheter.
• D. Administer the PRBCs with lactated Ringer's solution.

Correct answer: B

Rationale: Verifying the client's blood type and Rh factor is crucial before administering blood products to ensure compatibility and prevent adverse reactions. Option A is incorrect because PRBCs are typically infused over a specific time frame based on hospital policy and client condition, not necessarily over 8 hours. Option C is incorrect as PRBCs are usually administered through a larger gauge catheter to prevent hemolysis. Option D is incorrect because PRBCs are typically administered with normal saline and not lactated Ringer's solution.

4. 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.

5. A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?

• A. Contractions lasting 80 seconds.
• B. FHR baseline 170/min.
• C. Early decelerations in the FHR.
• D. Temperature 37.4°C (99.3°F).

Correct answer: B

Rationale: The correct answer is B. An FHR baseline of 170/min is considered tachycardia, which is above the normal range during labor and requires immediate attention. High FHR can indicate fetal distress or maternal fever. Choice A, contractions lasting 80 seconds, are within normal range for active labor. Choice C, early decelerations in the FHR, are usually benign and do not typically require immediate intervention. Choice D, a temperature of 37.4°C (99.3°F), is within normal limits.

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