Nursing Elites

1. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian for which of the following clients?

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: B

Rationale: The correct answer is B. A client with gout who plans to continue consuming anchovies should be referred to a dietitian for proper dietary education. Anchovies are high in purines, which can exacerbate gout symptoms. Choices A, C, and D do not require immediate dietitian referral as the statements made by these clients are appropriate actions regarding their prescribed medications (warfarin and spinach intake, spironolactone and potassium intake, and calcium carbonate and water intake, respectively).

2. A client with a new diagnosis of diabetes mellitus is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will eat a bedtime snack if my blood sugar is below 200 mg/dL.
• B. I will eat more sugar-free candy to help control my blood sugar.
• C. I will check my blood sugar every morning before breakfast.
• D. I will avoid physical activity if my blood sugar is below 100 mg/dL.

Correct answer: C

Rationale: The correct answer is C because checking blood sugar levels every morning before breakfast is a crucial aspect of managing diabetes effectively. This practice helps individuals monitor their blood sugar levels regularly and adjust their treatment plan as needed. Option A is incorrect as consuming a bedtime snack based on blood sugar levels alone may not be an appropriate approach to managing diabetes. Option B is incorrect as relying on more sugar-free candy does not address the overall dietary management of blood sugar levels. Option D is incorrect as avoiding physical activity when blood sugar is below 100 mg/dL can hinder diabetes management, as exercise is generally beneficial for controlling blood sugar levels.

3. A client in active labor requests pain management. Which of the following actions should the nurse take?

• A. Administer ondansetron.
• B. Place the client in a warm shower.
• C. Apply fundal pressure during contractions.
• D. Assist the client to a supine position.

Correct answer: B

Rationale: During active labor, nonpharmacologic comfort measures like placing the client in a warm shower are effective for pain relief. Ondansetron (Choice A) is an antiemetic and not used for pain management during labor. Applying fundal pressure (Choice C) can cause harm and is not recommended due to the risk of uterine rupture. Assisting the client to a supine position (Choice D) is not ideal in labor as it can decrease blood flow to the placenta and is associated with increased maternal complications.

4. During a change-of-shift report, a nurse is receiving information about an adult female client who is postoperative. Which of the following client information should the nurse report?

• A. The client's oxygen saturation is 95%
• B. The client's blood pressure is 110/70 mm Hg
• C. The client has a temperature of 36.8°C (98.2°F)
• D. The client's heart rate is 88/min

Correct answer: B

Rationale: The correct answer is B because a blood pressure of 110/70 mm Hg is within the normal range and stable. Reporting this information is crucial to monitor the client's condition postoperatively. Oxygen saturation of 95% is acceptable, a temperature of 36.8°C (98.2°F) is normal, and a heart rate of 88/min is within the expected range for an adult female client, so these values do not raise concerns that require immediate reporting.

5. Which of the following is a sign of digoxin toxicity?

• A. Bradycardia
• B. Hypertension
• C. Tachycardia
• D. Tachypnea

Correct answer: A

Rationale: The correct answer is A, Bradycardia. Bradycardia, or a slower than normal heart rate, is a classic sign of digoxin toxicity. Digoxin is a medication commonly used to treat heart conditions, but an excess of digoxin in the body can lead to toxicity. This toxicity can manifest as various symptoms, with bradycardia being one of the most common ones. Hypertension (high blood pressure) and tachycardia (fast heart rate) are not typical signs of digoxin toxicity. Tachypnea, which refers to rapid breathing, is also not a common sign of digoxin toxicity.

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