Nursing Elites

1. A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action?

• A. Implement a regular toileting schedule
• B. Encourage the client to wear athletic socks when ambulating
• C. Place all four bed rails in the upright position
• D. Require a family member to remain at the bedside

Correct answer: A

Rationale: Implementing a regular toileting schedule is an appropriate nursing action for a client at risk for falls. This action can help prevent accidents related to rushing to the bathroom. Encouraging the client to wear athletic socks when ambulating (Choice B) is not safe as it can increase the risk of slipping and falling. Placing all four bed rails in the upright position (Choice C) can lead to entrapment or falls when the client tries to get out of bed. Requiring a family member to remain at the bedside (Choice D) may not always be feasible and does not directly address fall prevention strategies like the toileting schedule.

2. What are the complications of untreated fluid overload?

• A. Pulmonary edema and congestive heart failure
• B. Hypertension and electrolyte imbalance
• C. Liver failure and electrolyte imbalance
• D. Pulmonary embolism and dehydration

Correct answer: A

Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.

3. A nurse is collecting data from a newly-admitted infant who is 3 months old and has diarrhea. Which of the following findings should the nurse report to the provider?

• A. Weight gain
• B. Poor appetite
• C. Irritability
• D. Decreased urination

Correct answer: C

Rationale: Irritability in infants can indicate worsening dehydration, which needs to be reported. Weight gain (Choice A) would be a positive finding, indicating adequate fluid intake. Poor appetite (Choice B) is common with diarrhea but not as concerning as irritability. Decreased urination (Choice D) can also be a sign of dehydration, but irritability is more specific to worsening dehydration in this case.

4. A client with asthma is being taught how to use a peak flow meter by a nurse. Which of the following instructions should the nurse include?

• A. Perform the test in the morning after taking medications
• B. Blow into the meter as slowly as possible
• C. Perform the test when feeling short of breath
• D. Use the peak flow meter after using your rescue inhaler

Correct answer: D

Rationale: The correct instruction is to use the peak flow meter after using the rescue inhaler. This ensures accurate monitoring of asthma control during symptoms. Choice A is incorrect because peak flow measurements should be done before taking medications. Choice B is incorrect as the client should blow into the meter quickly and forcefully to get an accurate reading. Choice C is also incorrect as peak flow should be measured regularly, not just when feeling short of breath.

5. A nurse is caring for a client who has a chest tube following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Drainage of 75 mL in the first hour after surgery.
• B. Constant bubbling in the water seal chamber.
• C. Tidaling in the water seal chamber.
• D. Client report of pain at the chest tube insertion site.

Correct answer: B

Rationale: Constant bubbling in the water seal chamber indicates an air leak, which should be reported to the provider. This finding suggests that the chest tube system is not functioning properly, leading to potential complications such as pneumothorax. Drainage of 75 mL in the first hour after surgery is within the expected range for a chest tube. Tidaling in the water seal chamber is a normal fluctuation and indicates proper functioning of the system. Client report of pain at the chest tube insertion site is expected after surgery and can be managed with appropriate pain management measures.

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