Nursing Elites

1. A nurse develops a plan of care for a client who has a history of hypocalcemia. What interventions should the nurse include in this clients care plan? (Select all that apply.)

• A. Use a draw sheet to reposition the client in bed.
• B. . Strain all urine output and assess for urinary stones.
• C. Provide nonslip footwear for the client to use when out of bed.
• D.

Correct answer: B

Rationale:

2. A nurse sees a variety of patients in the community health clinic. Which of the following patients would be at the greatest risk of dehydration?

• A. An 18-year-old basketball player with a stress fracture of the right foot
• B. An infant with diarrhea
• C. A 45-year-old with stomach flu
• D. An elderly patient living alone

Correct answer: B

Rationale: The correct answer is B. Infants are particularly vulnerable to dehydration due to diarrhea because they have a higher fluid turnover and less reserve. Option A, the 18-year-old basketball player with a stress fracture, is less likely to be at the greatest risk of dehydration compared to an infant with diarrhea. Option C, the 45-year-old with stomach flu, may experience dehydration but is not at the same level of risk as an infant with diarrhea. Option D, the elderly patient living alone, could be at risk of dehydration, but infants with diarrhea are at the greatest risk due to their unique physiological characteristics.

3. Which organ has the greatest effect on fluid output?

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

Correct answer: A

Rationale: The correct answer is the kidneys. The kidneys are primarily responsible for regulating fluid balance by filtering blood and adjusting the volume and concentration of urine. The lungs primarily regulate gas exchange, not fluid balance. The skin plays a role in temperature regulation and protection but is not the primary organ for fluid output. The intestines are mainly involved in the absorption of nutrients and water, rather than fluid output.

4. You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor?

• A. Overhydration is common among healthy older adults.
• B. Dehydration causes the skin to appear spongy.
• C. Inelastic skin turgor is a normal part of aging.
• D. Skin turgor cannot be assessed in patients over 70.

Correct answer: C

Rationale: Inelastic skin is a normal change of aging. However, this does not mean that skin turgor cannot be assessed in older patients. Dehydration, not overhydration, causes inelastic skin with tenting. Overhydration, not dehydration, causes the skin to appear edematous and spongy. Choice A is incorrect because overhydration is not common among healthy older adults. Choice B is incorrect because dehydration leads to inelastic skin, not sponginess. Choice D is incorrect as skin turgor assessment can be done in patients of any age, including those over 70.

5. . You are caring for a patient who has a diagnosis of syndrome of inappropriate antidiuretic hormone secretion (SIADH). Your patients plan of care includes assessment of specific gravity every 4 hours. The results of this test will allow the nurse to as

• A. Nutritional status
• B. Potassium balance
• C. Calcium balance
• D. Fluid volume status

Correct answer: D

Rationale:

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