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 nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate 16/min.
• B. Blood pressure 118/78 mm Hg.
• C. Urinary output of 30 mL/hr.
• D. Absent deep-tendon reflexes.

Correct answer: D

Rationale: The correct answer is D. Absent deep-tendon reflexes indicate magnesium toxicity and should be reported immediately. Magnesium sulfate is used to prevent seizures in clients with preeclampsia, but toxicity can lead to serious complications, including respiratory depression and loss of deep-tendon reflexes. Choices A, B, and C are within normal limits and expected findings in a client receiving magnesium sulfate for preeclampsia, so they do not require immediate reporting.

3. A nurse is reviewing the laboratory results of a client who is at 36 weeks of gestation. The nurse should report which of the following laboratory results to the provider?

• A. Hemoglobin 11.2 g/dL
• B. Platelet count 148,000/mm3
• C. Leukocyte count 9,000/mm3
• D. Blood glucose 80 mg/dL

Correct answer: A

Rationale: A hemoglobin level of 11.2 g/dL is below the normal range for a client who is 36 weeks gestation and should be reported to the provider.

4. A nurse is caring for a client who is 1 hour postoperative following a thoracentesis. Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 96%
• B. Tracheal deviation
• C. Pain level of 4 on a scale of 0 to 10
• D. Temperature of 37.4°C (99.3°F)

Correct answer: B

Rationale: Tracheal deviation is the correct finding to report to the provider. It can indicate a pneumothorax, which is a serious complication following a thoracentesis that requires immediate attention. Oxygen saturation of 96% is within the normal range and does not indicate an immediate issue. A pain level of 4 on a scale of 0 to 10 is subjective and may not be related to a serious complication. A temperature of 37.4°C (99.3°F) is slightly elevated but not a priority over tracheal deviation in this context.

5. A nurse is providing discharge teaching to a client who has a new prescription for metformin. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime.
• B. You should expect your urine to turn orange while taking this medication.
• C. This medication can cause you to gain weight.
• D. Take this medication with food to reduce gastrointestinal discomfort.

Correct answer: D

Rationale: The correct answer is D because taking metformin with food helps reduce gastrointestinal discomfort, a common side effect of the medication. Choice A is incorrect as metformin is usually taken with meals to minimize side effects. Choice B is incorrect because metformin does not typically cause urine discoloration. Choice C is incorrect as metformin is associated with weight loss or weight neutrality rather than weight gain.

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