Nursing Elites

1. A client who is at 30 weeks of gestation and is scheduled for a nonstress test is being taught by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should avoid drinking fluids during the test.
• B. I will need to drink a sugar solution before the test.
• C. This test will monitor how my baby is responding to contractions.
• D. This test will assess for fetal lung maturity.

Correct answer: B

Rationale: The correct answer is B because the client should drink a sugar solution for a glucose challenge test, which is part of the nonstress test protocol during pregnancy. Choice A is incorrect because adequate hydration is generally recommended before the test. Choice C is incorrect as the nonstress test monitors the baby's heart rate in response to its own movements, not contractions. Choice D is incorrect as the nonstress test does not assess fetal lung maturity.

2. A client is immediately postoperative following a hip arthroplasty. Which of the following positions should the nurse maintain for the client?

• A. Supine with legs extended
• B. Semi-Fowler's position with legs bent
• C. Lateral position with an abduction pillow between the legs
• D. Prone with legs elevated

Correct answer: C

Rationale: The correct position for a client immediately postoperative following a hip arthroplasty is the lateral position with an abduction pillow between the legs. This position helps prevent dislocation of the hip prosthesis and maintains proper alignment of the hip joint. Supine position with legs extended (Choice A) may put stress on the hip joint, Semi-Fowler's position with legs bent (Choice B) may not provide adequate support and alignment, and prone position with legs elevated (Choice D) is not recommended after hip arthroplasty as it can compromise the surgical site and increase the risk of complications.

3. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?

• A. Glasgow Coma Scale score of 15
• B. Blood drainage on the initial dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.

4. Which lab value is most critical to monitor in a patient receiving digoxin?

• A. Monitor potassium levels
• B. Monitor sodium levels
• C. Monitor calcium levels
• D. Monitor magnesium levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in a patient receiving digoxin. Hypokalemia can potentiate the toxic effects of digoxin, leading to serious cardiac arrhythmias. Monitoring potassium levels helps prevent toxicity. Monitoring sodium levels (Choice B), calcium levels (Choice C), and magnesium levels (Choice D) are also important aspects of patient care, but potassium levels are most critical in patients on digoxin therapy.

5. A nurse is preparing to administer an intermittent enteral feeding to a client who has a gastrostomy tube. Which of the following actions should the nurse take?

• A. Flush the tube with 30 mL of water after feeding
• B. Flush the tube with 10 mL of sterile water before feeding
• C. Place the client in a left lateral position
• D. Place the feeding bag 61 cm (24 in) above the client's abdomen

Correct answer: B

Rationale: Administering an intermittent enteral feeding through a gastrostomy tube requires flushing the tube with 10 mL of sterile water before feeding. This action helps ensure patency and prevents clogging. Choice A is incorrect because flushing after feeding does not address the need for pre-feeding tube flushing. Choice C is unrelated to tube feeding administration. Choice D is incorrect as the height of the feeding bag above the abdomen is typically regulated by healthcare facility policies and is not a universal standard.

Similar Questions