Nursing Elites

1. During an assessment, a healthcare professional is evaluating the body alignment of a standing patient. Which finding will the healthcare professional report as normal?

• A. When observed laterally, the spinal curves align in a reversed 'S' pattern.
• B. When observed posteriorly, the hips and shoulders form an 'S' pattern.
• C. The arms should be crossed over the chest or in the lap.
• D. The feet should be close together with toes pointed out.

Correct answer: A

Rationale: During a standing assessment, the healthcare professional should observe the patient laterally. In a normal body alignment, the head is erect, and the spinal curves align in a reversed 'S' pattern, aiding in maintaining balance and posture. Choice B is incorrect because hips and shoulders should be level and not form an 'S' pattern when observed posteriorly. Choice C is incorrect as the position of the arms is not a key indicator of body alignment. Choice D is incorrect as the feet should be shoulder-width apart with toes pointing forward for optimal balance and stability.

2. A healthcare professional is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid-volume deficit. Which of the following changes should the healthcare professional identify as an indication that the treatment was successful?

• A. Increase in hematocrit
• B. Increase in respiratory rate
• C. Decrease in heart rate
• D. Decrease in capillary refill time

Correct answer: C

Rationale: Fluid-volume deficit causes tachycardia. With correction of the imbalance, the heart rate should return to the expected range. An increase in hematocrit (Choice A) would indicate hemoconcentration, not a successful fluid replacement. An increase in respiratory rate (Choice B) could indicate respiratory distress or hypoxia, not improvement in fluid volume status. A decrease in capillary refill time (Choice D) may indicate improved peripheral perfusion but is not a direct indicator of fluid replacement success.

3. The LPN/LVN mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?

• A. 31 gtt/min.
• B. 62 gtt/min.
• C. 93 gtt/min.
• D. 124 gtt/min.

Correct answer: D

Rationale: To calculate the drops per minute for the client, first, convert the weight from pounds to kilograms by dividing 182 by 2.2, which equals 82.72 kg. Then, calculate the dose in mcg/min by multiplying the weight in kg by the rate (82.72 kg * 5 mcg/kg/min = 413.6 mcg/min). Next, convert 50 mg to mcg (50 mg * 1000 = 50,000 mcg). Divide the total mcg (50,000 mcg) by the dose per minute (413.6 mcg/min) to get approximately 121 gtt/min. However, since the drip factor is 60 gtt/ml, the correct answer is 124 gtt/min, ensuring the accurate administration rate of the medication. Therefore, choice 'D' is the correct answer. Choices 'A', 'B', and 'C' are incorrect as they do not accurately reflect the calculated drops per minute based on the given information.

4. A nurse is planning care for a client who has fluid overload. Which of the following actions should the nurse plan to take first?

• A. Evaluate electrolytes
• B. Restrict fluid intake
• C. Administer diuretics
• D. Monitor vital signs

Correct answer: A

Rationale: When a client has fluid overload, the nurse's first action should be to evaluate electrolytes. Electrolyte levels can be significantly affected by fluid imbalances, and assessing them will guide the nurse in determining the appropriate interventions. Restricting fluid intake (choice B) may be necessary but is not the initial priority. Administering diuretics (choice C) should be based on the electrolyte evaluation and overall assessment. Monitoring vital signs (choice D) is essential but does not provide direct information on the client's electrolyte status, which is crucial in managing fluid overload.

5. A nurse is calculating a client's fluid intake over the past 8 hr. Which of the following items should the nurse plan to document on the client's intake and output record as 120 mL of fluid?

• A. 2 cups of soup
• B. 1 quart of water
• C. 8 oz of ice chips
• D. 6 oz of tea

Correct answer: C

Rationale: The correct answer is C: 8 oz of ice chips. When calculating fluid intake, the nurse should document half of the volume of ice chips to account for the air in between the chips. Therefore, 8 oz of ice chips equals 120 mL of fluid. Choices A, B, and D are incorrect because they do not equate to 120 mL of fluid intake as per the given scenario. Choice A, 2 cups of soup, is more than 120 mL. Choice B, 1 quart of water, is significantly more than 120 mL. Choice D, 6 oz of tea, is less than 120 mL.

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