Nursing Elites

1. A nurse is assessing a client who has hyperthyroidism. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Dry skin.
• C. Cold intolerance.
• D. Tachycardia.

Correct answer: D

Rationale: The correct answer is D: Tachycardia. In clients with hyperthyroidism, tachycardia is a common finding due to the increased metabolic rate. Weight loss and heat intolerance are also expected due to the elevated metabolism. Choices A, B, and C (Weight gain, dry skin, cold intolerance) are not typical findings in hyperthyroidism, as the condition is associated with an overactive thyroid gland leading to an increase in metabolic functions.

2. A nurse is preparing to administer an intermittent enteral feeding to a client who has a nasogastric tube. Which of the following actions should the nurse take?

• A. Check for residual feeding contents.
• B. Administer the feeding through a large-bore syringe.
• C. Flush the tube with 10 mL of water after feeding.
• D. Administer the feeding at room temperature.

Correct answer: C

Rationale: The correct action for the nurse to take when preparing to administer an intermittent enteral feeding through a nasogastric tube is to flush the tube with 10 mL of water after feeding. This helps maintain tube patency and prevent clogging. Choice A, checking for residual feeding contents, is not the immediate action to take before administering the feeding. Choice B, administering the feeding through a large-bore syringe, is not the recommended method for administering enteral feedings. Choice D, administering the feeding at room temperature, is important but not the immediate action related to tube maintenance.

3. How should fluid balance in a patient with heart failure be monitored?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: The correct answer is to monitor daily weight. Daily weight monitoring is crucial in assessing fluid balance in patients with heart failure because sudden weight gain can indicate fluid retention. Monitoring input and output (choice B) is important but may not provide a complete picture of fluid balance. Checking for edema (choice C) is a sign of fluid accumulation but may not be as accurate as daily weight monitoring. Monitoring blood pressure (choice D) is important in heart failure management but does not directly assess fluid balance.

4. How should fluid overload in a patient with heart failure be managed?

• A. Administer diuretics
• B. Increase fluid intake
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.

5. A nurse is reviewing the medical record of a client who has a new prescription for insulin glargine. Which of the following should the nurse include in the teaching?

• A. This insulin has a peak effect of 2 to 4 hours.
• B. This insulin has a duration of action of 24 hours.
• C. This insulin is given before meals to control your blood sugar.
• D. You should avoid eating 30 minutes before or after taking this insulin.

Correct answer: B

Rationale: The correct answer is B. Insulin glargine has a 24-hour duration of action, making it suitable for once-daily dosing for long-term blood sugar control. Choice A is incorrect as insulin glargine is a long-acting insulin with no pronounced peak effect in its action profile. Choice C is incorrect as insulin glargine is usually given at the same time each day regardless of meals. Choice D is incorrect as there is no specific requirement to avoid eating before or after taking insulin glargine.

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