Nursing Elites

1. A nurse is teaching a prenatal class about infection. Which statement by the client indicates further teaching is required?

• A. I can visit someone with chickenpox 5 days after the sores crust.
• B. I should avoid eating foods that contain high folic acid.
• C. I can clean my cat's litter box during pregnancy.
• D. I should wash my hands with hot water for 10 seconds after gardening.

Correct answer: C

Rationale: The correct answer is C because cleaning a cat's litter box during pregnancy can increase the risk of toxoplasmosis, which can be harmful to the developing fetus. Choice A is correct as the statement indicates understanding of the chickenpox transmission timeline. Choice B is also correct as high folic acid foods are beneficial during pregnancy. Choice D is correct as washing hands with hot water after gardening helps prevent infections.

2. A nurse is caring for a client who has a pulmonary embolism. The nurse should identify the effectiveness of the treatment by observing which of the following?

• A. A chest x-ray reveals increased density in all fields
• B. The client reports feeling less anxious
• C. Diminished breath sounds are auscultated bilaterally
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg

Correct answer: B

Rationale: The correct answer is B because when a client reports feeling less anxious, it suggests that the treatment for a pulmonary embolism is effective. This is a good indicator of the client's overall well-being and response to treatment. Choices A, C, and D are incorrect because a chest x-ray revealing increased density in all fields, diminished breath sounds auscultated bilaterally, and ABG results showing specific values do not directly correlate with the effectiveness of treatment for a pulmonary embolism. While these assessments are important for monitoring the client's condition, the client's subjective report of feeling less anxious provides a more direct insight into the impact of the treatment.

3. A nurse is caring for a client who is 36 weeks gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Proteinuria of 1+.
• B. Blood pressure 120/80 mm Hg.
• C. Respiratory rate of 18/min.
• D. Nonpitting ankle edema.

Correct answer: D

Rationale: Nonpitting ankle edema is a concerning sign of worsening preeclampsia due to fluid retention and should be reported immediately. Proteinuria of 1+ is a common finding in preeclampsia. A blood pressure of 120/80 mm Hg is within normal limits. A respiratory rate of 18/min is also within normal range. Therefore, choices A, B, and C are not as urgent as nonpitting ankle edema in this scenario.

4. What is the most important nursing action for a patient presenting with confusion after surgery?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer IV fluids
• D. Perform a neurological assessment

Correct answer: A

Rationale: Administering oxygen is crucial for a patient presenting with confusion after surgery because it helps alleviate potential hypoxia, which can be a common cause of confusion in the postoperative period. While repositioning the patient, administering IV fluids, and performing a neurological assessment are important nursing interventions in certain situations, addressing hypoxia by administering oxygen takes priority in this case to ensure an adequate oxygen supply to the brain and other vital organs.

5. A nurse is caring for a client who has heart failure and a prescription for digoxin. Which of the following findings should the nurse identify as a manifestation of digoxin toxicity?

• A. Constipation.
• B. Tachycardia.
• C. Visual disturbances.
• D. Hypertension.

Correct answer: C

Rationale: Visual disturbances, such as blurred or yellow vision, are common signs of digoxin toxicity. While constipation (Choice A) is not typically associated with digoxin toxicity, tachycardia (Choice B) and hypertension (Choice D) are not characteristic manifestations of digoxin toxicity. Therefore, the correct answer is visual disturbances (Choice C).

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