Nursing Elites

1. Postoperative client with fluid volume deficit. Which change indicates successful treatment?

• A. Decrease in heart rate
• B. Increase in blood pressure
• C. Decrease in respiratory rate
• D. Increase in urine output

Correct answer: A

Rationale: A decrease in heart rate can indicate improved fluid balance and successful treatment of fluid volume deficit. When a client is experiencing fluid volume deficit, the heart rate typically increases as a compensatory mechanism to maintain cardiac output. As fluid volume is restored and the deficit is corrected, the heart rate should decrease back towards a normal range. Choices B, C, and D are less likely to be directly related to the successful treatment of fluid volume deficit. An increase in blood pressure may occur as a compensatory response to fluid volume deficit; a decrease in respiratory rate is not a typical indicator of fluid volume deficit correction; and an increase in urine output can be a sign of improved kidney function but may not directly reflect fluid volume status.

2. When planning interventions for a group of clients who are obese, what can the nurse do to improve their commitment to a long-term goal of weight loss?

• A. Developing a strict diet plan
• B. Attempting to develop the clients’ self-motivation
• C. Providing frequent rewards
• D. Encouraging group exercise

Correct answer: B

Rationale: To improve clients' commitment to a long-term goal of weight loss, attempting to develop their self-motivation is crucial. Self-motivation is essential for sustaining behavior changes over time. Providing a strict diet plan (choice A) may not address the root motivation needed for long-term success. While rewards (choice C) can be motivating, relying solely on external rewards may not foster the intrinsic motivation required for sustained weight loss. Encouraging group exercise (choice D) is beneficial, but without addressing individual motivation, it may not lead to long-term commitment to weight loss goals.

3. A nurse is preparing to administer ketorolac 0.5 mg/kg IV bolus every 6 hr to a school-age child who weighs 66 lb. The available ketorolac injection is 30 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

• A. 0.5 mL
• B. 1 mL
• C. 1.5 mL
• D. 2 mL

Correct answer: A

Rationale: To calculate the dose, first convert the weight from pounds to kilograms. The child weighs 66 lb, which is approximately 30 kg. The prescribed dose is 0.5 mg/kg, so for a 30 kg child, the dose would be 0.5 mg/kg x 30 kg = 15 mg. Since the available ketorolac injection is 30 mg/mL, the nurse should administer 15 mg ÷ 30 mg/mL = 0.5 mL per dose. Therefore, choice A (0.5 mL) is the correct answer. Choices B, C, and D are incorrect as they do not accurately calculate the correct dose based on the child's weight and the concentration of the ketorolac injection.

4. The nurse is caring for an older adult patient diagnosed with Alzheimer's disease who is ambulatory but requires total assistance with activities of daily living (ADLs). The nurse notices that the patient is edentulous. Which area should the nurse assess?

• A. Assess oral cavity.
• B. Assess room for drafts.
• C. Assess ankles for edema.
• D. Assess for reduced sensations.

Correct answer: A

Rationale: The correct answer is to assess the oral cavity. 'Edentulous' means without teeth, so the nurse should assess the oral cavity for any issues related to oral health, dentures, or potential complications. This assessment is crucial to prevent oral health problems and ensure proper care for the patient. Assessing the room for drafts (choice B) is unrelated to the patient's edentulous status and does not address the immediate care needs. Assessing ankles for edema (choice C) is important for circulatory assessment but not directly related to the patient being edentulous. Assessing for reduced sensations (choice D) would be more relevant for neurological or sensory concerns, which are not specifically associated with being edentulous.

5. The client is receiving discharge instructions for a new antihypertensive medication. Which statement by the client indicates a need for further teaching?

• A. I will stop taking the medication if I experience dizziness.
• B. I will monitor my blood pressure regularly.
• C. I will avoid drinking alcohol while taking this medication.
• D. I will rise slowly from a sitting to a standing position.

Correct answer: A

Rationale: The correct answer is A. Stopping antihypertensive medication abruptly can lead to rebound hypertension, which can be dangerous. Clients should never discontinue their medication without consulting their healthcare provider first. Choice B is correct because monitoring blood pressure is essential when taking antihypertensive medication to ensure it stays within the target range. Choice C is correct as alcohol can potentiate the hypotensive effects of antihypertensive medications. Choice D is correct as orthostatic hypotension can occur, so rising slowly helps prevent dizziness and falls. Therefore, choice A is the statement that indicates a need for further teaching.

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