Nursing Elites

1. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

• A. Ask family members to speak quietly to keep the client calm.
• B. Assess urine color, amount, and specific gravity each day.
• C. Encourage the client to drink at least 1 liter of fluids each shift.
• D. Dangle the client on the bedside before ambulating.

Correct answer: D

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.

2. When selecting a site on the hand or arm for insertion of an IV catheter, the nurse should:

• A. Choose a proximal site.
• B. Choose a distal site.
• C. Have the patient hold their arm in a dependent position.
• D. Leave the tourniquet on for no longer than 2 minutes.

Correct answer: B

Rationale: When selecting a site for insertion of an IV catheter, the nurse should choose a distal site, not a proximal site. Opting for a distal site ensures that upper veins remain available for future cannulations. Instructing the patient to hold their arm in a dependent position can enhance blood flow, aiding in the procedure. It is crucial never to leave a tourniquet on for more than 2 minutes as prolonged restriction can lead to complications. Choice A is incorrect because a proximal site is not preferred for IV insertion. Choice C is incorrect as having the patient hold their arm over their head is not necessary and may impede proper blood flow. Choice D is incorrect as leaving the tourniquet on for at least 5 minutes is excessive and can be harmful.

3. What is the most important regulator of the amount of sodium in the body?

• A. Kidneys
• B. Small intestine
• C. Large intestine
• D. Skin

Correct answer: A

Rationale: The correct answer is A: Kidneys. The kidneys play a crucial role in regulating the amount of sodium in the body. They achieve this by filtering blood and controlling the excretion or reabsorption of sodium. The small intestine is primarily responsible for nutrient absorption, not sodium regulation. The large intestine is mainly involved in water absorption and waste elimination, not sodium balance. The skin helps regulate body temperature through sweating and does not directly regulate sodium levels.

4. During a visit to an 84-year-old woman recovering from hip surgery, the nurse notices signs of confusion and poor skin turgor. The woman mentions she limits water intake to avoid nighttime bathroom trips. The nurse should explain to the woman that:

• A. She will need her medications adjusted and be readmitted for a complete workup.
• B. Limiting fluids can lead to body imbalances causing confusion; perhaps adjusting fluid intake timing is necessary.
• C. Post-surgical confusion is common, and it's safe not to urinate at night.
• D. Confusion after surgery is typical in the elderly due to sleep loss.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid and electrolyte imbalances can manifest with subtle signs like confusion. Limiting fluids can lead to such imbalances, affecting cognitive function. Adjusting the timing of fluid intake can help maintain hydration without causing nighttime disruptions. Choices A, C, and D are incorrect. Choice A suggests unnecessary hospital readmission and medication adjustments without addressing the root cause. Choice C wrongly normalizes the confusion and fails to address the potential issue of fluid restriction. Choice D incorrectly attributes confusion solely to sleep loss without considering the impact of fluid balance.

5. Under normal circumstances, the kidneys provide the greatest means of water loss. Which organ provides the second greatest means of water loss?

• A. Skin
• B. Lungs
• C. Intestines
• D. Muscles

Correct answer: A

Rationale: The correct answer is A: Skin. After the kidneys, the skin is the second largest route of water loss through perspiration. Choice B, Lungs, is incorrect as the lungs primarily exchange gases and do not play a significant role in water loss. Choice C, Intestines, is also incorrect as water loss through the intestines is minimal since most water is reabsorbed during digestion. Choice D, Muscles, is incorrect as muscles are not a major source of water loss in the body.

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