Nursing Elites

1. What instruction should the nurse provide a pregnant client experiencing heartburn?

• A. Limit fluid intake between meals to prevent stomach over-distension
• B. Take an antacid at bedtime and when symptoms worsen
• C. Maintain an upright position for two hours after eating
• D. Eat small meals throughout the day to avoid a full stomach

Correct answer: D

Rationale: The correct answer is D: 'Eat small meals throughout the day to avoid a full stomach.' Heartburn is common in pregnancy due to increased intra-abdominal pressure and hormonal changes. Consuming small, frequent meals prevents the stomach from becoming overly full, reducing the likelihood of acid reflux and heartburn. Choice A is incorrect because limiting fluid intake between meals may not significantly impact heartburn. Choice B is not ideal as antacids should be taken as directed by a healthcare provider, not just at bedtime or when symptoms worsen. Choice C is less effective advice, as maintaining an upright position after eating may not directly address the root cause of heartburn.

2. A client with active tuberculosis (TB) is receiving isoniazid (INH) and rifampin (RMP) daily, so direct observation therapy (DOT) is initiated while the client is hospitalized. Which instruction should the nurse provide this client?

• A. Describe feelings about taking daily medications
• B. Take medications in the presence of the nurse
• C. Notify the nurse after self-medication is completed
• D. Keep a daily record of all medications taken

Correct answer: B

Rationale: The correct instruction for the nurse to provide the client undergoing direct observation therapy for TB is to take medications in the presence of the nurse. This approach ensures that the client is actually taking the medications as prescribed, reducing the risk of noncompliance. Choice A is incorrect because the focus should be on ensuring the client physically takes the medications rather than discussing feelings. Choice C is incorrect as it does not ensure direct observation. Choice D is incorrect because self-reporting or keeping a record does not guarantee that the client is actually taking the medications.

3. A 20-year-old female client tells the nurse that her menstrual periods occur about every 28 days, and her breasts are quite tender when her menstrual flow is heavy. She also states that she performs her breast self-examination (BSE) on the first day of every month. What action should the nurse implement in response to the client’s statements?

• A. Remind the client that it is also important to schedule an annual mammogram.
• B. Refer the client to a nurse practitioner for an in-depth review of the BSE procedure.
• C. Encourage the client to perform BSE 2 to 3 days after her menstrual period ends.
• D. Instruct the client to continue with her regular monthly exams as she is doing.

Correct answer: C

Rationale: The correct answer is to encourage the client to perform BSE 2 to 3 days after her menstrual period ends. This timing is recommended because breasts are least tender and swollen at this point, making it easier to detect any abnormalities. Choice A is incorrect because while scheduling an annual mammogram is important, it is not the immediate action needed based on the client's statements. Choice B is incorrect as the client's BSE technique timing needs adjustment rather than an in-depth review by a nurse practitioner. Choice D is incorrect because the client should modify the timing of the BSE for better effectiveness.

4. After receiving report, which client should the nurse assess last?

• A. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
• B. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed
• C. An older client with a distended abdomen and no drainage from the nasogastric tube
• D. An adult client with rectal tube draining clear pale red liquid drainage

Correct answer: D

Rationale: The correct answer is D because the client with rectal tube drainage of clear pale red liquid is likely to be the least urgent since this is a normal post-operative finding. Clear pale red liquid drainage from a rectal tube is typically not a cause for immediate concern. Choices A, B, and C present clients with concerning signs that may require more immediate assessment and intervention. A client with dark red drainage on a postoperative dressing may indicate active bleeding, a client with a compressed Jackson-Pratt drain bulb may have inadequate drainage resulting in complications, and a client with a distended abdomen and no drainage from the nasogastric tube may be experiencing gastrointestinal issues that need prompt evaluation.

5. The nurse is caring for a comatose client. Which assessment finding provides the greatest indication that the client has an open airway?

• A. The client has asymmetrical chest expansion
• B. Percussion reveals dullness over the lung area
• C. Bilateral breath sounds can be auscultated
• D. The client has been turned q2h

Correct answer: C

Rationale: The correct answer is C: "Bilateral breath sounds can be auscultated." This finding indicates that air is moving adequately in and out of both lungs, confirming an open airway. Options A, B, and D are incorrect. Asymmetrical chest expansion may indicate lung or chest wall abnormalities, percussion revealing dullness over the lung area may suggest consolidation or fluid, and turning the client q2h is a position change intervention to prevent complications, not a direct assessment of airway patency.

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