Nursing Elites

1. How should fluid overload in a patient with heart failure be managed?

• A. Administer diuretics
• B. Increase fluid intake
• C. Provide oral fluids
• D. Provide chest physiotherapy

Correct answer: A

Rationale: Administering diuretics is the appropriate management for fluid overload in a patient with heart failure. Diuretics help to reduce fluid retention by increasing urine output, thereby alleviating the fluid overload. Choices B, C, and D are incorrect. Increasing fluid intake would worsen the condition by adding more fluid to an already overloaded system. Providing oral fluids is not specific enough to address the excess fluid in the body, and chest physiotherapy is not indicated for managing fluid overload in heart failure patients.

2. A client is 2 hours postoperative following a cholecystectomy. Which of the following interventions should the nurse implement?

• A. Place the client in a supine position
• B. Administer morphine for pain relief
• C. Apply a warm compress to the incision site
• D. Place a pillow under the client's knees

Correct answer: B

Rationale: Administering morphine for pain relief is crucial for postoperative clients following a cholecystectomy to manage pain effectively. Placing the client in a supine position may not be ideal as it can cause discomfort and hinder breathing. Applying a warm compress to the incision site can increase the risk of infection. Placing a pillow under the client's knees is not a priority intervention compared to pain management.

3. A client with bipolar disorder and experiencing mania is under the care of a nurse. Which intervention should the nurse include in the plan?

• A. Encourage the client to spend time in the day room.
• B. Withdraw the client's TV privileges if they do not attend group therapy.
• C. Encourage the client to take frequent rest periods.
• D. Place the client in seclusion when they exhibit signs of anxiety.

Correct answer: C

Rationale: Encouraging the client to take frequent rest periods is an appropriate intervention for managing mania in a client with bipolar disorder. During a manic episode, individuals often have increased energy levels, decreased need for sleep, and may engage in high-risk behaviors. Encouraging regular rest periods can help reduce stimulation and promote relaxation, which may assist in stabilizing mood. Choices A and B are not as effective in managing manic symptoms, as they do not directly address the client's need for rest and relaxation. Choice D is inappropriate because placing the client in seclusion can increase feelings of anxiety and agitation, worsening the manic episode.

4. A client who is 2 hours postoperative following a kidney biopsy is being assessed by a nurse. Which of the following findings should the nurse report to the provider?

• A. Urinary output of 30 mL/hr.
• B. Hemoglobin 10 g/dL.
• C. Respiratory rate of 16/min.
• D. Blood pressure 110/70 mm Hg.

Correct answer: B

Rationale: The correct answer is B. A hemoglobin level of 10 g/dL is below the normal range and should be reported following a kidney biopsy to check for bleeding. Decreased hemoglobin levels could indicate internal bleeding, which is a significant concern postoperatively. Choices A, C, and D are within normal limits and do not require immediate reporting. Urinary output of 30 mL/hr is also within the acceptable range for a postoperative client. A respiratory rate of 16/min and blood pressure of 110/70 mm Hg are both normal findings postoperatively.

5. A client is receiving opioid analgesics for pain management. Which of the following assessments is the priority?

• A. Monitor the client's blood pressure.
• B. Check the client's urinary output.
• C. Monitor the client's respiratory rate.
• D. Assess the client's pain level.

Correct answer: C

Rationale: The correct answer is C: Monitor the client's respiratory rate. When a client is receiving opioid analgesics, the priority assessment is monitoring respiratory rate. Opioids can cause respiratory depression, so it is crucial to assess the client's breathing to detect any signs of respiratory distress promptly. Checking the client's blood pressure (Choice A) and urinary output (Choice B) are important assessments too, but they are not the priority when compared to ensuring adequate respiratory function. Assessing the client's pain level (Choice D) is essential for overall care but is not the priority assessment when the client is on opioids, as respiratory status takes precedence.

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