Nursing Elites

1. A client with type 2 diabetes mellitus is concerned about weight gain during pregnancy. Which of the following responses should the nurse make?

• A. You should not gain more than 10 lbs
• B. Your weight gain should be the same as for someone without diabetes
• C. Avoid gaining more than 15 lbs
• D. You should gain more weight because of your condition

Correct answer: B

Rationale: The correct answer is B. Clients with type 2 diabetes should aim for the same pregnancy weight gain as those without diabetes. Option A is too restrictive and may not be appropriate for a healthy pregnancy. Option C also imposes a specific limit without considering individual needs. Option D is incorrect as excessive weight gain can lead to complications in pregnancy, especially for individuals with diabetes.

2. A client receiving chemotherapy has developed stomatitis. Which of the following actions should the nurse take?

• A. Provide lemon-glycerin swabs
• B. Encourage the client to eat soft foods
• C. Avoid using toothpaste
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: B

Rationale: The correct action for the nurse to take when caring for a client with stomatitis due to chemotherapy is to encourage the client to eat soft foods. Soft foods help prevent further irritation to the already inflamed and sore oral mucosa. Providing lemon-glycerin swabs may further irritate the mucosa due to the acidic nature of lemon. Avoiding toothpaste is advisable as many toothpaste products contain ingredients that can aggravate stomatitis. Instructing the client to use a mouthwash containing alcohol is contraindicated as alcohol-based mouthwashes can be too harsh and drying for the already sensitive oral tissues.

3. How should a healthcare professional assess a patient with a suspected infection?

• A. Monitor temperature and check for elevated white blood cells
• B. Monitor blood pressure and check for fever
• C. Assess for changes in mental status and monitor urine output
• D. Administer antibiotics and monitor for changes in mental status

Correct answer: A

Rationale: When assessing a patient with a suspected infection, it is crucial to monitor temperature and check for elevated white blood cells. Elevated temperature indicates a potential infection, and increased white blood cells are a sign of inflammation and the body's response to an infection. Monitoring blood pressure (choice B) and checking for fever (choice B) are not as specific indicators of infection as monitoring temperature and white blood cell count. Assessing changes in mental status and monitoring urine output (choice C) are important aspects of patient assessment but may not directly indicate a suspected infection. Administering antibiotics (choice D) should only be done after a confirmed diagnosis of a bacterial infection, as unnecessary antibiotic use can lead to antibiotic resistance and other adverse effects.

4. A nurse in a long-term care facility is contributing to the plan of care for a client who has a new ostomy. Which of the following interventions should the nurse include?

• A. Change the appliance daily
• B. Clean the stoma once a day
• C. Avoid changing the appliance for a week
• D. Change the appliance twice each week

Correct answer: D

Rationale: The correct answer is to change the appliance twice each week. Changing the appliance too frequently can irritate the skin around the stoma, while not changing it often enough can lead to infection. Changing the appliance twice a week helps to maintain hygiene without causing irritation. Choices A, B, and C are incorrect because changing the appliance daily can cause irritation, cleaning the stoma once a day may not be sufficient for proper hygiene, and avoiding changing the appliance for a week can increase the risk of infection and skin breakdown.

5. A client at 30 weeks of gestation reports constipation. Which of the following recommendations should the nurse make?

• A. Drink 1 liter of water per day.
• B. Take a laxative every morning.
• C. Increase your intake of refined grains.
• D. Walk for at least 30 minutes every day.

Correct answer: D

Rationale: The correct recommendation is to walk for at least 30 minutes every day. Walking stimulates intestinal motility, which can help relieve constipation during pregnancy. Option A is important for overall hydration but may not directly address constipation. Option B is not recommended without healthcare provider approval as some laxatives are contraindicated in pregnancy. Option C, increasing intake of refined grains, may exacerbate constipation due to lower fiber content.

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