Nursing Elites

1. How should signs of dehydration in an elderly patient be assessed?

• A. Monitor skin turgor
• B. Check for dry mucous membranes
• C. Monitor for sunken eyes
• D. Check capillary refill

Correct answer: A

Rationale: Corrected Rationale: Monitoring skin turgor is a reliable method to assess dehydration in elderly patients. Skin turgor refers to the skin's elasticity or the skin's ability to return to its normal position after being pinched. In dehydration, the skin loses its elasticity, becoming less flexible and slower to return to its original state. Checking for dry mucous membranes (Choice B), monitoring for sunken eyes (Choice C), and checking capillary refill (Choice D) are all relevant assessments in dehydration but are not as specific or sensitive as monitoring skin turgor. Dry mucous membranes and sunken eyes are indicators of dehydration, while capillary refill is more related to circulatory status and less specific to dehydration.

2. A client who has a new prescription for lithium is receiving discharge teaching from a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will need to have my blood levels checked regularly while taking this medication.
• B. I should take this medication on an empty stomach.
• C. I should avoid eating foods that are high in sodium.
• D. I should stop taking this medication if I experience nausea.

Correct answer: A

Rationale: The correct answer is A. Clients prescribed lithium need regular monitoring of blood levels to ensure the medication's effectiveness and safety. This monitoring helps to keep the medication within the therapeutic range and prevent toxicity. Choice B is incorrect because lithium is usually taken with food to minimize gastrointestinal side effects. Choice C is not directly related to lithium therapy; however, excessive sodium intake can affect lithium levels. Choice D is incorrect as abruptly stopping lithium can lead to adverse effects and should only be done under healthcare provider guidance.

3. A nurse is planning care for a client who has dehydration. Which of the following interventions should the nurse include?

• A. Monitor the client's fluid intake.
• B. Provide the client with a high-protein diet.
• C. Encourage the client to ambulate frequently.
• D. Administer 0.45% sodium chloride IV.

Correct answer: D

Rationale: The correct intervention for a client with dehydration is to administer 0.45% sodium chloride IV. This solution helps correct fluid imbalance by providing the necessary electrolytes. Restricting fluid intake (Choice A) is not appropriate for dehydration as the client needs adequate fluids to rehydrate. Providing a high-protein diet (Choice B) is not directly related to correcting dehydration. Encouraging the client to ambulate frequently (Choice C) is beneficial for overall health but does not address the issue of dehydration directly.

4. Which of the following is the most concerning electrolyte imbalance for a patient on furosemide?

• A. Hypokalemia
• B. Hyperkalemia
• C. Hyponatremia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is Hypokalemia. Furosemide, a loop diuretic, can lead to potassium depletion in the body, causing hypokalemia. This is a significant concern as low potassium levels can result in cardiac arrhythmias and other serious complications. Hyperkalemia (Choice B) is unlikely to occur as a result of furosemide use. Hyponatremia (Choice C) is more commonly associated with thiazide diuretics. Hypercalcemia (Choice D) is not typically linked to furosemide use.

5. A client who has a new diagnosis of hypertension is being taught about dietary modifications by a nurse. Which of the following instructions should the nurse include?

• A. Limit fluid intake to 2 liters per day.
• B. Increase your intake of whole grains.
• C. Eat 3 large meals daily.
• D. Consume foods high in potassium.

Correct answer: B

Rationale: The correct answer is B: 'Increase your intake of whole grains.' Whole grains are beneficial for individuals with hypertension as they can help promote heart health. Whole grains are high in fiber, which can help lower blood pressure. Option A is incorrect as fluid intake should be adequate but not restricted to 2 liters per day. Option C is incorrect as it is recommended to have smaller, more frequent meals rather than 3 large meals to help manage hypertension. Option D is incorrect; although foods high in potassium can be beneficial for hypertension, the most appropriate dietary modification to include in this scenario is increasing whole grain intake.

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