Nursing Elites

1. What assessment is most important for the nurse to perform for a client with dehydration receiving IV fluids?

• A. Monitor the client’s electrolyte levels.
• B. Check the client’s urine output hourly.
• C. Assess the client’s skin turgor regularly.
• D. Monitor the client’s blood pressure every 15 minutes.

Correct answer: A

Rationale: The correct answer is to monitor the client’s electrolyte levels. When a client is receiving IV fluids for dehydration, it is crucial to assess their electrolyte levels regularly. Dehydration can lead to imbalances in electrolytes, especially sodium and potassium, which are essential for maintaining fluid balance and proper organ function. Checking urine output (Choice B) is important but not as critical as monitoring electrolyte levels. Assessing skin turgor (Choice C) is an indirect method of assessing dehydration but does not provide specific information about electrolyte imbalances. Monitoring blood pressure (Choice D) is important but not the most critical assessment in this scenario as electrolyte imbalances can have a more direct impact on the client's condition.

2. The nurse is providing care for a client with advanced liver disease who is experiencing ascites. Which intervention should the nurse implement to help manage the client's fluid volume?

• A. Increase the client's sodium intake
• B. Encourage the client to drink more fluids
• C. Place the client in a supine position
• D. Administer a diuretic as prescribed

Correct answer: D

Rationale: Administering a diuretic as prescribed is the most appropriate intervention to manage fluid volume in a client with ascites due to advanced liver disease. Diuretics help reduce fluid accumulation in the body, including the abdominal cavity where ascites occurs. Increasing sodium intake would worsen fluid retention, and encouraging more fluid intake can exacerbate ascites. Placing the client in a supine position does not directly address the fluid volume issue associated with ascites.

3. A client is experiencing acute bronchospasm. What is the nurse's priority intervention?

• A. Administer a nebulizer treatment of albuterol.
• B. Start an IV infusion of normal saline.
• C. Administer oxygen at 4L/min via nasal cannula.
• D. Position the client in a high Fowler's position.

Correct answer: A

Rationale: The correct answer is to administer a nebulizer treatment of albuterol. In acute bronchospasm, the priority intervention is to deliver a bronchodilator like albuterol to open the airways and improve breathing. Starting an IV infusion of normal saline (Choice B) may be necessary but not the priority in this situation. Administering oxygen at 4L/min via nasal cannula (Choice C) is important but not the first intervention for bronchospasm. Positioning the client in a high Fowler's position (Choice D) can help with breathing but is not the priority over administering a bronchodilator.

4. The nurse is feeding an older adult who was admitted with aspiration pneumonia. The client is weak and begins coughing while attempting to drink through a straw. Which intervention should the nurse implement?

• A. Encourage the client to drink more slowly
• B. Stop feeding and assess for signs of aspiration
• C. Elevate the head of the bed further
• D. Teach coughing and deep breathing exercises

Correct answer: B

Rationale: When an older adult with aspiration pneumonia coughs while attempting to drink, it may indicate aspiration. Aspiration can lead to serious complications. Therefore, the appropriate intervention for the nurse in this situation is to stop feeding immediately and assess the client for signs of aspiration. Encouraging the client to drink more slowly (Choice A) may not address the risk of aspiration. Elevating the head of the bed further (Choice C) is generally beneficial to prevent aspiration but is not the priority when immediate assessment is needed. Teaching coughing and deep breathing exercises (Choice D) is not appropriate when the client is actively coughing during feeding and requires immediate assessment for potential aspiration.

5. A male client with HIV receiving saquinavir PO in combination with other antiretrovirals reports constant hunger and thirst but is losing weight. What action should the nurse implement?

• A. Use a glucometer to check glucose level.
• B. Teach client to measure weight accurately.
• C. Explain that medication dose may need to be increased.
• D. Reassure client weight will increase as viral load decreases.

Correct answer: A

Rationale: The correct action for the nurse to implement is to use a glucometer to check the client's glucose level. Saquinavir, an HIV medication, can lead to hyperglycemia, which may cause symptoms like constant hunger and thirst while losing weight. Checking the glucose level will help assess for hyperglycemia. Choice B is not the priority in this situation as the client's weight loss is a concerning symptom that needs immediate attention. Choice C is incorrect because increasing the medication dose without assessing the glucose level first could exacerbate hyperglycemia. Choice D is incorrect as it does not address the symptoms of constant hunger, thirst, and weight loss, which may indicate a more urgent issue like hyperglycemia.

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