Nursing Elites

1. A client is at risk for excess fluid volume. Which nursing intervention ensures the most accurate monitoring of the client’s fluid status?

• A. Measuring and recording fluid intake and output
• B. Weighing the client daily at the same time each day
• C. Assessing the client’s vital signs every 4 hours
• D. Checking the client’s lungs for crackles during every shift

Correct answer: B

Rationale: The correct answer is B. Weighing the client daily at the same time each day is the most accurate method for monitoring fluid balance. Changes in body weight can indicate fluid retention or loss. Measuring and recording fluid intake and output (choice A) is important but may not reflect total body fluid status accurately. Assessing vital signs (choice C) and checking the client's lungs for crackles (choice D) are important assessments but do not directly provide the most accurate monitoring of fluid status.

2. In patients receiving chemotherapy, which nutrient is often supplemented to manage mucositis?

• A. Vitamin E
• B. Vitamin B12
• C. Zinc
• D. Calcium

Correct answer: C

Rationale: Zinc supplementation is often recommended to manage mucositis in patients undergoing chemotherapy. Zinc plays a crucial role in wound healing and immune function, which can help alleviate the symptoms of mucositis. Vitamin E (Choice A) is known for its antioxidant properties but is not typically used to manage mucositis. Vitamin B12 (Choice B) is important for red blood cell production and nerve function but is not directly associated with mucositis management. Calcium (Choice D) is essential for bone health and muscle function but is not a primary nutrient supplemented to manage mucositis.

3. The nurse administers 2 units of salt-poor albumin to a client with portal hypertension and ascites. The nurse explains to the client that this is administered to:

• A. Provide nutrients
• B. Increase protein stores
• C. Elevate the circulating blood volume
• D. Divert blood flow away from the liver temporarily

Correct answer: C

Rationale: The correct answer is C: Elevate the circulating blood volume. Salt-poor albumin is given to increase the circulating blood volume, which helps reduce ascites by improving fluid distribution within the body. Choices A, B, and D are incorrect because salt-poor albumin is not administered to provide nutrients, increase protein stores, or divert blood flow away from the liver.

4. A family came to the emergency department with complaints of food poisoning. Which client should the nurse see first?

• A. 32-year-old with diarrhea for 6 hours
• B. 2-year-old with 1 wet diaper in 24 hours
• C. 40-year-old with abdominal cramping
• D. 10-year-old who is nauseated

Correct answer: B

Rationale: The correct answer is B because a 2-year-old with reduced urine output (1 wet diaper in 24 hours) is at high risk for dehydration. Dehydration can occur rapidly in young children and can be life-threatening. The nurse should prioritize assessing and managing the dehydration of the 2-year-old. Choices A, C, and D, although they may also require attention, do not present the same level of immediate risk as a dehydrated 2-year-old.

5. What is the best position for any procedure that involves vaginal and cervical examination?

• A. Dorsal recumbent
• B. Side lying
• C. Supine
• D. Lithotomy

Correct answer: D

Rationale: The lithotomy position is the most suitable position for procedures involving vaginal and cervical examination because it provides the best access to the vaginal and cervical regions. In this position, the patient lies on their back with their legs flexed and feet placed in stirrups, allowing for optimal visualization and access to the area. This position facilitates proper examination, diagnosis, and treatment when working in the gynecological field. Choices A, B, and C are incorrect as they do not provide the necessary exposure and access required for a thorough vaginal and cervical examination. Dorsal recumbent, side lying, and supine positions may limit visibility and hinder the examination process in such cases.

Similar Questions