Nursing Elites

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

• A. 8 oz of ice chips
• B. 8 oz of ice chips
• C. 1 cup of broth
• D. 1 cup of broth

Correct answer: A

Rationale: Choice A, '8 oz of ice chips,' is the correct answer. 8 oz is equivalent to approximately 240 mL, and since 1 oz is roughly equal to 30 mL, 8 oz would be approximately 240 mL. Since the question specifies 120 mL of fluid, this option does not match. Choices C and D, '1 cup of broth,' do not equate to 120 mL. A standard cup is approximately 240 mL, which is double the amount mentioned in the question. Therefore, choice A is the most accurate representation of 120 mL of fluid intake.

2. The healthcare provider is caring for a client with dehydration. Which assessment finding indicates that the client is responding to treatment?

• A. Dry mucous membranes
• B. Increased urine output
• C. Decreased heart rate
• D. Elevated blood pressure

Correct answer: B

Rationale: Increased urine output is the correct assessment finding that indicates the client is responding to treatment for dehydration. When a client is dehydrated, their urine output tends to decrease as the body tries to conserve fluids. Therefore, an increase in urine output suggests that the client's hydration status is improving. Dry mucous membranes (Choice A) are a sign of dehydration and would not indicate a positive response to treatment. Decreased heart rate (Choice C) and elevated blood pressure (Choice D) are not specific indicators of hydration status in a client with dehydration.

3. The LPN/LVN is assisting with the care of a client who has had a stroke. Which intervention is most important to include in the client's plan of care to prevent joint contractures?

• A. Encourage the client to perform active range-of-motion exercises.
• B. Use pillows to keep the client's extremities in a functional position.
• C. Place the client in a prone position for 30 minutes each day.
• D. Perform passive range-of-motion exercises on the affected side.

Correct answer: B

Rationale: Using pillows to keep the client's extremities in a functional position is crucial in preventing joint contractures. This intervention helps maintain proper alignment of the joints and reduces the risk of contractures by preventing prolonged positioning that can lead to muscle shortening. Encouraging the client to perform active range-of-motion exercises (Choice A) is beneficial for maintaining mobility but may not be the most important intervention to prevent joint contractures. Placing the client in a prone position for 30 minutes each day (Choice C) can be helpful for preventing pressure ulcers but is not directly related to preventing joint contractures. Performing passive range-of-motion exercises on the affected side (Choice D) can aid in maintaining joint flexibility but may not be as crucial as using pillows to prevent joint contractures.

4. A client scheduled for arthroplasty expresses concern about the risk of acquiring an infection from a blood transfusion. Which of the following statements should the nurse make to the client?

• A. Donate autologous blood before the surgery
• B. Request a specific blood type from the donor
• C. Use blood from a family member
• D. Accept allogeneic blood without concerns

Correct answer: A

Rationale: The correct statement for the nurse to make to the client is to 'Donate autologous blood before the surgery.' Autologous blood donation involves collecting and storing the client's own blood for potential use during surgery, which significantly reduces the risk of transfusion-related infections. This option directly addresses the client's concern about infection risk. Requesting a specific blood type from a donor (Choice B) is not as effective in reducing infection risk compared to autologous blood donation. Using blood from a family member (Choice C) carries the risk of transfusion reactions and infections due to compatibility issues. Accepting allogeneic blood without concerns (Choice D) does not address the client's specific concern about infection risk and is not the most appropriate option in this situation.

5. How should the nurse transcribe the dosage of this medication on the client's medical record?

• A. 0.3 mg
• B. 0.3 mg
• C. 0.30 mg
• D. 3/10 mg

Correct answer: B

Rationale: The correct way to transcribe the dosage of three tenths of a milligram of levothyroxine IV STAT is 0.3 mg. When expressing decimals less than 1, there should be a leading zero before the decimal point. Choice A is incorrect (.3 mg) because it lacks the leading zero. Choice C (0.30 mg) is incorrect as it includes a trailing zero after the decimal point, which is unnecessary. Choice D (3/10 mg) is incorrect as it presents the dosage as a fraction, which is not the standard format for transcribing medication dosages. Therefore, B (0.3 mg) is the most appropriate and accurate way to document this prescription on the client's medical record.

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