Nursing Elites

1. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?

• A. Place the patient in low Fowler's position and notify the physician.
• B. Increase the patient's IV fluid and auscultate the lungs.
• C. Place the patient in semi-Fowler's position and prepare to give the PRN diuretic as ordered.
• D. Discontinue the patient's IV.

Correct answer: C

Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.

2. A nurse in the medical-surgical unit has a newly admitted patient who is oliguric; the acute care nurse practitioner orders a fluid challenge of 100 to 200 mL of normal saline solution over 15 minutes. The nurse is aware this intervention will help:

• A. Distinguish hyponatremia from hypernatremia
• B. Evaluate pituitary gland function
• C. Distinguish reduced renal blood flow from decreased renal function
• D. Provide an effective treatment for hypertension-induced oliguria

Correct answer: C

Rationale: Administering a fluid challenge in oliguric patients helps to distinguish reduced renal blood flow from decreased renal function. This intervention aids in determining whether the oliguria is due to reduced renal blood flow (such as in fluid volume deficit or prerenal azotemia) or decreased renal function (such as in acute tubular necrosis). The response to this challenge can indicate the underlying cause. Choices A, B, and D are incorrect as they do not align with the purpose of a fluid challenge in oliguric patients.

3. A nurse is planning care for a client who is hyperventilating. The clients arterial blood gas values are pH 7.30, PaO2 94 mm Hg, PaCO2 31 mm Hg, and HCO3 26 mEq/L. Which question should the nurse ask when developing this clients plan of care?

• A. Do you take any over-the-counter medications?
• B. You appear anxious. What is causing your distress?
• C. Do you have a history of anxiety attacks?
• D. You are breathing fast. Is this causing you to feel light-headed?

Correct answer: B

Rationale:

4. The nurse is caring for a patient in metabolic alkalosis. The patient has an NG tube to low intermittent suction for a diagnosis of bowel obstruction. What drug would the nurse expect to find on the medication orders?

• A. Cimetidine
• B. Maalox
• C. Potassium chloride elixir
• D. ) Furosemide

Correct answer: A

Rationale:

5. A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance should the nurse assess? (Select all that do mot apply.)

• A. Electrocardiogram changes
• B. Slow, shallow respirations
• C. Paralytic ileus
• D. Skeletal muscle weakness

Correct answer: B

Rationale:

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