Nursing Elites

1. A nurse is collecting data from a postpartum client who had a vaginal birth 2 days ago. Which of the following findings is the nurse's priority to report to the provider?

• A. Bright red bleeding
• B. Burning with urination
• C. Headache
• D. Heavy lochia flow

Correct answer: B

Rationale: The correct answer is B: 'Burning with urination.' Burning with urination can indicate a urinary tract infection postpartum, which requires immediate attention to prevent complications. Bright red bleeding and heavy lochia flow are expected findings in the early postpartum period as the uterus continues to contract and expel lochia. A headache alone is not uncommon postpartum and is often attributed to hormonal changes, dehydration, or fatigue, and can be managed with adequate rest, hydration, and pain relief. Therefore, the priority here is to address the potential infection indicated by burning with urination.

2. A nurse is performing postmortem care for a client prior to the arrival of the client's family for viewing of the body. Which of the following actions should the nurse take?

• A. Apply moisturizing lotion to the skin
• B. Turn off the lights
• C. Remove all jewelry
• D. Gently close the client's eyelids

Correct answer: D

Rationale: The correct action the nurse should take is to gently close the client's eyelids. This is a respectful and common practice in postmortem care before allowing the family to view the body. Applying moisturizing lotion to the skin is unnecessary and may not be appropriate at this time. Turning off the lights might not be necessary and could impact the viewing environment for the family. While removing all jewelry is generally a good practice, it is not as crucial as gently closing the client's eyelids for postmortem care.

3. A client has a prescription for ranitidine 150 mg PO BID. Available is ranitidine syrup 15 mg/mL. How many mL should the nurse administer each day?

• A. 20 mL
• B. 15 mL
• C. 25 mL
• D. 10 mL

Correct answer: A

Rationale: To administer a total of 300 mg daily (150 mg PO BID), the nurse should give 20 mL of the syrup. This is calculated by dividing the total daily dose (300 mg) by the concentration of the syrup (15 mg/mL), which equals 20 mL. Choice B (15 mL), C (25 mL), and D (10 mL) are incorrect because they do not accurately calculate the required volume of syrup needed to deliver the prescribed dose.

4. A nurse is caring for a client who has hypokalemia. Which of the following clinical findings should the nurse expect?

• A. Hyperactive reflexes.
• B. Strong, bounding pulse.
• C. Decreased bowel sounds.
• D. Increased deep tendon reflexes.

Correct answer: C

Rationale: The correct answer is C: Decreased bowel sounds. In hypokalemia, decreased bowel sounds are common due to slowed peristalsis. Hyperactive reflexes (choice A) and increased deep tendon reflexes (choice D) are more indicative of hyperkalemia. A strong, bounding pulse (choice B) is not typically associated with hypokalemia.

5. A nurse is teaching a client who has heart failure about fluid restrictions. Which of the following instructions should the nurse include?

• A. Limit fluid intake to 3 liters per day
• B. Limit fluid intake to 1-2 liters per day
• C. Drink 4 liters of water per day
• D. Restrict water intake to 1 liter per day

Correct answer: B

Rationale: The correct answer is B: 'Limit fluid intake to 1-2 liters per day.' For clients with heart failure, fluid restriction is essential to prevent fluid overload. Restricting fluid intake to 1-2 liters per day helps maintain fluid balance and prevents exacerbation of heart failure symptoms. Choices A, C, and D are incorrect because consuming 3 liters, 4 liters, or limiting water intake to 1 liter per day, respectively, can lead to fluid overload in clients with heart failure.

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