Nursing Elites

1. An elderly client is admitted with a diagnosis of bacterial pneumonia. The nurse's assessment of the client will most likely reveal which sign/symptom?

• A. Leukocytosis and febrile.
• B. Polycythemia and crackles.
• C. Pharyngitis and sputum production.
• D. Confusion and tachycardia.

Correct answer: D

Rationale: The onset of pneumonia in the elderly may be signaled by general deterioration, confusion, increased heart rate or increased respiratory rate due to the decreased oxygen- carbon dioxide exchange at the alveoli, known as the V-Q mismatch.

2. The client with chronic renal failure is receiving peritoneal dialysis. Which of the following is the most important action for the nurse to take?

• A. Administer the prescribed antibiotics.
• B. Monitor for signs of infection.
• C. Encourage the client to increase fluid intake.
• D. Monitor the client's weight daily.

Correct answer: B

Rationale: Monitoring for signs of infection is crucial in clients undergoing peritoneal dialysis. Peritonitis is a severe complication associated with peritoneal dialysis, making it essential to promptly identify any signs of infection, such as abdominal pain, cloudy dialysate, fever, and an elevated white blood cell count. Administering antibiotics without proper assessment can lead to antibiotic resistance and should not be the initial action. Encouraging increased fluid intake may not be appropriate without assessing the client's fluid status. Monitoring weight alone does not address the immediate risk of peritonitis in a client undergoing peritoneal dialysis.

3. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take?

• A. Document findings and continue to monitor the client.
• B. Contact the provider and recommend a 24-hour urine test.
• C. Review the client’s recent dietary selections.
• D. Perform a capillary artery glucose assessment.

Correct answer: D

Rationale: Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the client’s dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

4. The nurse is administering intravenous fluids to a dehydrated patient. On the second day of care, the patient's weight has increased by 2.25 pounds. The nurse would expect that the patient's fluid intake has

• A. equaled urine output.
• B. exceeded urine output by 1 L.
• C. exceeded urine output by 2.5 L.
• D. exceeded urine output by 3 L.

Correct answer: B

Rationale: A weight gain of 1 kg, or approximately 2.2 to 2.5 lb, is generally equivalent to 1 liter (L) of fluid retained by the body. In this case, the patient's weight gain of 2.25 pounds suggests an excess fluid retention of approximately 1 liter, indicating that the patient's fluid intake has exceeded urine output by 1 liter. Choices C and D are incorrect as they overestimate the fluid excess based on the patient's weight gain. Choice A is incorrect as it implies an exact balance between fluid intake and urine output, which is not reflected in the given weight increase.

5. What is a priority intervention for a patient experiencing a thyroid storm?

• A. Administering antipyretics.
• B. Cooling the patient.
• C. Administering beta-blockers.
• D. Administering antithyroid medications.

Correct answer: D

Rationale: During a thyroid storm, the priority intervention is to administer antithyroid medications to reduce thyroid hormone levels quickly. These medications, such as propylthiouracil or methimazole, help inhibit the production of thyroid hormones. Administering antipyretics (choice A) may help reduce fever, but it does not address the underlying cause of the thyroid storm. Cooling the patient (choice B) may provide symptomatic relief but does not address the thyroid hormone dysregulation. Administering beta-blockers (choice C) can help manage symptoms like tachycardia and hypertension, but it does not target the root cause of the thyroid storm.

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