Nursing Elites

1. How should fluid balance be assessed in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: Corrected Rationale: Monitoring daily weight is the most accurate method to assess fluid balance in patients receiving diuretics. Changes in weight reflect changes in fluid balance, making it a sensitive indicator. Monitoring intake and output (choice B) is important but may not provide a complete picture of overall fluid balance. Checking for edema (choice C) is a late sign of fluid imbalance and may not be sensitive enough to detect subtle changes. Monitoring blood pressure (choice D) is relevant but may not directly reflect fluid balance as it can be influenced by various other factors.

2. A client receiving intermittent enteral feedings is being cared for by a nurse. Which action should the nurse take to reduce the risk of aspiration?

• A. Administer the feeding over 60 minutes.
• B. Position the client in a supine position during feedings.
• C. Elevate the head of the bed to 45 degrees during feedings.
• D. Flush the feeding tube with 60 mL of water before each feeding.

Correct answer: C

Rationale: The correct action to reduce the risk of aspiration during enteral feedings is to elevate the head of the bed to 45 degrees. This position helps prevent the reflux of feeding into the lungs. Administering the feeding over 60 minutes (Choice A) does not directly reduce the risk of aspiration. Positioning the client in a supine position (Choice B) increases the risk of aspiration as it promotes reflux. Flushing the feeding tube with water (Choice D) is important for tube patency but does not directly reduce the risk of aspiration.

3. What is the most important assessment for a patient with suspected pneumonia?

• A. Monitor lung sounds
• B. Check oxygen saturation
• C. Assess for cough
• D. Assess for fever

Correct answer: A

Rationale: The most important assessment for a patient with suspected pneumonia is to monitor lung sounds. Lung sounds provide crucial information about the severity of pneumonia, such as crackles or decreased air entry. This assessment helps in evaluating the effectiveness of ventilation and oxygenation. While checking oxygen saturation is important, monitoring lung sounds gives more direct information about the lung involvement in pneumonia. Assessing for cough and fever are also relevant but do not provide as direct and critical information as monitoring lung sounds in the context of suspected pneumonia.

4. A nurse is assessing a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as an indication of digoxin toxicity?

• A. Bradycardia.
• B. Tachycardia.
• C. Nausea.
• D. Blurred vision.

Correct answer: D

Rationale: Corrected Rationale: Blurred vision is a classic sign of digoxin toxicity, indicating a potential overdose. It is crucial to recognize this symptom promptly and report it to the healthcare provider for immediate intervention. Bradycardia and nausea are common side effects of digoxin but not specific indicators of toxicity. Tachycardia is unlikely in digoxin toxicity since it usually causes a decrease in heart rate.

5. A healthcare provider is reviewing the medical record of a client who has Cushing's disease. Which of the following findings should the healthcare provider expect?

• A. Decreased serum glucose level
• B. Increased lymphocyte count
• C. Increased serum potassium level
• D. Decreased serum sodium level

Correct answer: C

Rationale: In Cushing's disease, there is increased cortisol production, which can lead to various metabolic disturbances. One of the common findings is an increased serum potassium level. The other options are incorrect because Cushing's disease typically causes hyperglycemia, not decreased serum glucose levels (A), lymphocytopenia, not increased lymphocyte count (B), and hyponatremia, not decreased serum sodium level (D).

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