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 nurse is providing teaching to a client who is receiving radiation therapy for cancer of the larynx. Which of the following instructions should the nurse include?

• A. Apply heat to the neck to relieve pain.
• B. Use a soft-bristle toothbrush to prevent gum irritation.
• C. Rinse your mouth with an alcohol-free mouthwash twice daily.
• D. Wear loose-fitting clothing to protect your skin.

Correct answer: B

Rationale: The correct answer is to use a soft-bristle toothbrush to prevent gum irritation in clients undergoing radiation therapy for laryngeal cancer. Radiation therapy can cause oral mucositis and increase the risk of gum irritation, so using a soft-bristle toothbrush is recommended to minimize trauma to the gums and oral mucosa. Applying heat to the neck is contraindicated as it can exacerbate tissue damage caused by radiation. Rinsing the mouth with an alcohol-free mouthwash is preferred over an alcohol-based one to prevent drying and irritation of the oral mucosa. Wearing loose-fitting clothing is advised to prevent friction and irritation on the skin, rather than tight-fitting clothing that may cause pressure ulcers or skin breakdown.

3. A nurse is caring for a child who has cystic fibrosis and is receiving postural drainage. Which of the following actions should the nurse take?

• A. Perform the procedure after meals.
• B. Administer bronchodilators before the procedure.
• C. Hold hand flat to perform percussion.
• D. Perform the procedure twice a day.

Correct answer: C

Rationale: The correct action the nurse should take when caring for a child with cystic fibrosis receiving postural drainage is to hold the hand flat to perform percussion. This technique allows for effective chest physiotherapy. Choice A is incorrect because postural drainage should be performed before meals to prevent vomiting during the procedure. Choice B is incorrect because bronchodilators are typically administered before postural drainage to help open up the airways. Choice D is incorrect as the frequency of postural drainage may vary depending on the individual's condition, so performing it twice a day may not be appropriate for all patients.

4. A client post-thyroidectomy reports tingling in their lips and fingers. The nurse should identify this finding as an indication of which of the following complications?

• A. Hypokalemia
• B. Hypocalcemia
• C. Hyponatremia
• D. Hyperglycemia

Correct answer: B

Rationale: Tingling in the lips and fingers is a classic sign of hypocalcemia, which can occur as a complication following a thyroidectomy due to inadvertent damage to the parathyroid glands that regulate calcium levels. Hypokalemia (Choice A) presents with muscle weakness and cardiac issues, not tingling. Hyponatremia (Choice C) typically manifests with confusion, seizures, and muscle cramps. Hyperglycemia (Choice D) is associated with increased thirst, frequent urination, and fatigue.

5. A nurse is assessing a client who has been taking lithium for bipolar disorder. Which of the following findings should the nurse report to the provider?

• A. Tremors
• B. Increased thirst
• C. Weight gain
• D. Diarrhea

Correct answer: A

Rationale: Corrected Rationale: Tremors can indicate lithium toxicity, which should be reported to the provider for further evaluation. Tremors are a significant sign of lithium toxicity and can lead to serious complications if not addressed promptly. Increased thirst, weight gain, and diarrhea are common side effects of lithium but are not typically indicative of toxicity. Therefore, the nurse should prioritize reporting tremors as it requires immediate attention.

Similar Questions