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. A client receiving IV heparin reports tarry stools and abdominal pain. What interventions should the nurse implement?

• A. Prepare to administer warfarin.
• B. Assess the characteristics of the client's pain.
• C. Obtain recent partial thromboplastin time results.
• D. Monitor stool for the presence of blood.

Correct answer: D

Rationale: The correct intervention for the client receiving IV heparin who reports tarry stools and abdominal pain is to monitor the stool for the presence of blood. This is crucial to assess for gastrointestinal bleeding, a potential complication of heparin therapy. Assessing the characteristics of the client's pain may be helpful but is not the priority when signs of GI bleeding are present. Administering warfarin is not appropriate without a thorough assessment and confirmation of the cause of symptoms. While obtaining recent partial thromboplastin time results is important in monitoring heparin therapy, in this scenario, the immediate concern is to assess for possible GI bleeding.

3. A client receiving heparin therapy experiences a drop in platelet count. What is the nurse's priority action?

• A. Continue to monitor the platelet count.
• B. Discontinue the heparin infusion.
• C. Administer platelet transfusion.
• D. Notify the healthcare provider immediately.

Correct answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. A drop in platelet count during heparin therapy may indicate heparin-induced thrombocytopenia (HIT), a serious condition that increases the risk of clot formation. Immediate discontinuation of heparin is necessary to prevent further complications. Administering platelet transfusion without addressing the underlying cause can be harmful. Continuing to monitor the platelet count without taking immediate action can lead to delayed intervention. Notifying the healthcare provider promptly allows for assessment and initiation of alternative anticoagulation therapy to manage the client's condition effectively.

4. A client presents to the clinic with concerns about her left breast. Which assessment finding is most important for the nurse to report?

• A. Multiple firm, round, freely movable masses.
• B. A slight asymmetry of the breasts.
• C. A fixed nodular mass with dimpling of the skin.
• D. Bloody discharge from the nipple.

Correct answer: C

Rationale: The correct answer is C. A fixed nodular mass with dimpling of the skin is concerning for malignancy, such as breast cancer, and should be reported immediately for further evaluation. This finding is more suspicious compared to multiple firm, round, freely movable masses (choice A), which could be benign breast lumps. A slight asymmetry of the breasts (choice B) is a common finding and not as alarming as a fixed nodular mass with dimpling of the skin. Bloody discharge from the nipple (choice D) can be suggestive of other conditions like intraductal papilloma but is not as urgent as the finding described in choice C.

5. A female client with acute respiratory distress syndrome (ARDS) is sedated and on a ventilator with 50% FIO2. What assessment finding warrants immediate intervention?

• A. Assess the client’s lung sounds bilaterally.
• B. Diminished left lower lobe sounds.
• C. Monitor ventilator settings for changes in oxygen levels.
• D. Increased sputum production and shortness of breath.

Correct answer: B

Rationale: Diminished breath sounds in a sedated client with ARDS and on a ventilator indicate collapsed alveoli, which requires immediate intervention, such as chest tube insertion, to prevent further lung damage. Assessing bilateral lung sounds (Choice A) is important but not as urgent as identifying diminished sounds in a specific location. Monitoring ventilator settings (Choice C) is essential but does not directly address the immediate need for intervention due to diminished breath sounds. Increased sputum production and shortness of breath (Choice D) may indicate other issues but are not specific to the urgency of addressing diminished breath sounds in ARDS.

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