Nursing Elites

1. A healthcare professional is assessing a client for signs of fluid overload. Which of the following findings should the healthcare professional look for?

• A. Weight loss
• B. Decreased blood pressure
• C. Edema
• D. Increased urine output

Correct answer: C

Rationale: Edema is a common sign of fluid overload. When the body retains more fluid than it excretes, it can lead to edema, which is swelling caused by excess fluid trapped in body tissues. Weight gain, not weight loss, is typically associated with fluid overload due to the retained fluids. Decreased blood pressure is more commonly associated with dehydration rather than fluid overload. Increased urine output is a sign of the body trying to eliminate excess fluids, which is contrary to the signs of fluid overload.

2. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig’s sign?

• A. After stroking the lateral area of the foot, the client’s toes contract and draw together
• B. After hip flexion, the client is unable to extend their leg completely without pain
• C. The client’s voluntary movement is not coordinated
• D. The client reports pain and stiffness when flexing their neck

Correct answer: B

Rationale: A positive Kernig’s sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding indicates meningeal irritation. Choices A, C, and D do not describe Kernig’s sign. Choice A describes a normal plantar reflex, choice C refers to coordination issues, and choice D describes neck pain and stiffness, which are not specific to Kernig’s sign.

3. A client receiving IV moderate (conscious) sedation with midazolam has a respiratory rate of 9/min and is not responding to commands. Which of the following is an appropriate action by the nurse?

• A. Place the client in a prone position
• B. Implement positive pressure ventilation
• C. Perform nasopharyngeal suctioning
• D. Administer flumazenil

Correct answer: D

Rationale: In this scenario, the client is showing signs of respiratory depression and central nervous system depression due to midazolam sedation. Administering flumazenil is the correct action as it is the antidote for midazolam, a benzodiazepine, and can reverse the sedative effects to restore respiratory function. Placing the client in a prone position (choice A) may worsen respiratory compromise. Implementing positive pressure ventilation (choice B) is not the first-line intervention for sedation-related respiratory depression. Performing nasopharyngeal suctioning (choice C) is not indicated as there are no signs of airway obstruction requiring suctioning.

4. A nurse in a provider's office is assessing a client who reports a decrease in the effectiveness of their arthritis medication. Which client information should the nurse identify as a contributing factor to the decrease in the medication's effectiveness?

• A. Taking the medication with water
• B. Skipping doses of medication
• C. A history of recurring bowel inflammation
• D. Taking anti-inflammatory medication without food

Correct answer: C

Rationale: The correct answer is C. A history of recurring bowel inflammation can impact the absorption and effectiveness of arthritis medication. Bowel inflammation can affect the body's ability to absorb the medication properly, leading to decreased effectiveness. Choices A, B, and D do not directly relate to the decreased effectiveness of the arthritis medication. Taking medication with water, skipping doses, or taking anti-inflammatory medication without food may not be ideal practices but are not directly linked to the decrease in effectiveness reported by the client.

5. A nurse on an acute med-surgical unit is performing assessments on a group of clients. Which is the highest priority?

• A. Client with surgical hypoparathyroidism and positive Trousseau's sign
• B. Client with Clostridium difficile and acute diarrhea
• C. Client with acute kidney injury and low urine specific gravity
• D. Client with oral cancer and reports a sore on his gums

Correct answer: A

Rationale: The correct answer is A. A positive Trousseau's sign indicates hypocalcemia, which can lead to life-threatening complications like tetany or laryngospasm, making it the highest priority. Choices B, C, and D, while important, do not pose immediate life-threatening risks compared to the potential complications of severe hypocalcemia seen in a client with surgical hypoparathyroidism and a positive Trousseau's sign.

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