Nursing Elites

1. How should a healthcare provider monitor a patient with fluid overload?

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

Correct answer: A

Rationale: Monitoring daily weight is crucial in assessing fluid retention accurately in a patient with fluid overload. Changes in weight can indicate fluid accumulation or loss, providing valuable information for healthcare providers. Checking for edema (choice B) is important but may not always accurately reflect total body fluid status. Monitoring input and output (choice C) and blood pressure (choice D) are also essential aspects of patient assessment, but they may not directly reflect the extent of fluid overload as effectively as monitoring daily weight.

2. A nurse is reviewing the laboratory values of a client who is receiving heparin therapy for deep-vein thrombosis. Which of the following values should the nurse report to the provider?

• A. INR 2.0
• B. Platelet count 150,000/mm3
• C. aPTT 60 seconds
• D. WBC count 8,000/mm3

Correct answer: C

Rationale: The correct answer is C: aPTT 60 seconds. An aPTT of 60 seconds is above the therapeutic range for clients on heparin therapy and indicates a risk of bleeding, so it should be reported to the provider. INR of 2.0 is within the therapeutic range for clients on heparin therapy, so it does not require immediate reporting. Platelet count of 150,000/mm3 and WBC count of 8,000/mm3 are within normal ranges and not directly related to heparin therapy, so they do not need to be reported in this context.

3. A client is receiving intermittent enteral tube feedings. Which of the following places the client at risk for aspiration?

• A. A history of gastroesophageal reflux disease.
• B. Receiving a high-osmolarity formula.
• C. Sitting in a high-Fowler's position during the feeding.
• D. A residual of 65 mL 1 hr post-feeding.

Correct answer: A

Rationale: The correct answer is A. Clients with a history of gastroesophageal reflux disease are at risk for aspiration due to the potential of regurgitation, which can lead to aspiration of stomach contents into the lungs. Choice B (receiving a high-osmolarity formula) can lead to issues like diarrhea or dehydration but is not directly related to aspiration. Choice C (sitting in a high-Fowler's position during the feeding) is actually a preventive measure to reduce the risk of aspiration. Choice D (a residual of 65 mL 1 hr post-feeding) is a concern for delayed gastric emptying but not a direct risk factor for aspiration.

4. A client is receiving intermittent enteral tube feedings and is experiencing dumping syndrome. Which of the following actions should the nurse take?

• A. Administer a refrigerated feeding.
• B. Increase the amount of water used to flush the tubing.
• C. Decrease the rate of the client's feedings.
• D. Instruct the client to move onto their right side.

Correct answer: C

Rationale: Dumping syndrome is a condition that occurs when food moves too quickly from the stomach into the small intestine. Symptoms can include abdominal cramping, diarrhea, and sweating. To manage dumping syndrome in a client receiving enteral tube feedings, the nurse should decrease the rate of the feedings. This intervention helps slow down the movement of food through the gastrointestinal tract, reducing the symptoms. Administering a refrigerated feeding (choice A) or increasing the amount of water used to flush the tubing (choice B) are not appropriate actions for addressing dumping syndrome. Instructing the client to move onto their right side (choice D) is not a relevant intervention for managing dumping syndrome in this scenario.

5. When discussing clients designating a health care proxy in situations requiring a durable power of attorney for health care (DPAHC), what information should the charge nurse include?

• A. The proxy should make health care decisions for the client regardless of the client's ability to do so.
• B. The proxy can make financial decisions if the need arises.
• C. The proxy can make treatment decisions if the client is under anesthesia.
• D. The proxy should manage legal issues for the client.

Correct answer: C

Rationale: The correct answer is C. The charge nurse should include information that the proxy can make treatment decisions if the client is under anesthesia. This is a key function of a durable power of attorney for health care. Choices A, B, and D are incorrect because a health care proxy's role is specifically related to making health care decisions, not financial decisions, legal issues, or decisions made under anesthesia.

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