Nursing Elites

1. How should a healthcare professional assess for fluid overload in a patient with heart failure?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor blood pressure
• D. Check oxygen saturation

Correct answer: A

Rationale: Monitoring daily weight is the most accurate way to assess fluid overload in patients with heart failure. In heart failure, the body retains excess fluid, leading to weight gain. Monitoring daily weight allows healthcare professionals to track fluid retention accurately. Checking for edema (Choice B) is a valuable assessment technique, but it may not be as sensitive as monitoring daily weight. Monitoring blood pressure (Choice C) is essential in managing heart failure, but it is not the most accurate way to assess fluid overload. Checking oxygen saturation (Choice D) is important to assess respiratory status but is not directly related to fluid overload in heart failure.

2. A nurse is assessing a client who is 1 day postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Blood pressure of 110/70 mm Hg
• B. Heart rate of 88/min
• C. Respiratory rate of 20/min
• D. Temperature of 37.3°C (99.1°F)

Correct answer: D

Rationale: The correct answer is D because a temperature of 37.3°C (99.1°F) is slightly elevated, indicating a possible infection or inflammatory response, which should be reported to the provider for further evaluation. Choices A, B, and C are within normal limits for a client postoperative, so they do not require immediate reporting. Elevated temperature can be a sign of infection or other complications, making it a priority for reporting and further assessment.

3. A nurse is preparing to administer packed RBCs to a client. Which of the following actions should the nurse take first?

• A. Prime the IV tubing with dextrose 5% in water
• B. Ensure the client's consent is on file
• C. Check the client's identification using two identifiers
• D. Administer the blood through a 22-gauge catheter

Correct answer: C

Rationale: The correct first action for the nurse to take when preparing to administer packed RBCs is to check the client's identification using two identifiers. This step is crucial to ensure that the right blood is given to the right client, preventing any transfusion errors. Priming the IV tubing with dextrose 5% in water and administering the blood through a 22-gauge catheter are important steps but should come after confirming the client's identity. Ensuring the client's consent is on file is also important but is not the immediate priority when preparing to administer packed RBCs.

4. What is the best method to monitor fluid balance in a patient receiving diuretics?

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

Correct answer: A

Rationale: The best method to monitor fluid balance in a patient receiving diuretics is to monitor daily weight. Daily weighing is a precise way to assess changes in fluid status as it reflects variations in total body water. Monitoring intake and output (choice B) is also important but may not provide as accurate a measurement as daily weight. Monitoring blood pressure (choice C) is essential but does not directly measure fluid balance. Monitoring edema (choice D) is helpful to assess fluid status visually but may not be as sensitive as daily weight measurements in detecting subtle changes in fluid balance.

5. What is the appropriate action when a patient experiences an allergic reaction to a medication?

• A. Administer epinephrine
• B. Discontinue the medication
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for a severe allergic reaction as it helps to constrict blood vessels, increase heart rate, and open airways, thereby improving breathing and circulation. Discontinuing the medication may not be sufficient to manage a severe allergic reaction as the allergen is already in the patient's system. Corticosteroids and antihistamines can be considered as complementary treatments but are not the primary immediate intervention required for a severe allergic reaction.

Similar Questions