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 assessing the respiratory system for complications of immobility, what action should the nurse take?

• A. Inspect chest wall movements primarily during the expiratory cycle.
• B. Auscultate the entire lung region to assess lung sounds.
• C. Focus auscultation on the upper lung fields.
• D. Assess the patient at least every 4 hours.

Correct answer: B

Rationale: The correct action for the nurse when assessing the respiratory system for complications of immobility is to auscultate the entire lung region. This approach allows the nurse to identify any diminished breath sounds, crackles, or wheezes that may indicate respiratory issues. Inspecting chest wall movements primarily during the expiratory cycle (Choice A) may not provide a comprehensive assessment of lung sounds. Focusing auscultation on the upper lung fields (Choice C) may miss important findings in the lower lung fields. Assessing the patient at least every 4 hours (Choice D) is important for monitoring overall patient condition but does not specifically address the assessment of respiratory complications related to immobility.

3. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take?

• A. Carefully remove the gloves and follow with hand hygiene
• B. Continue with the procedure and clean hands later
• C. Remove the gloves, wash hands, and start over
• D. Use hand sanitizer and continue the procedure

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to carefully remove the gloves and follow with hand hygiene. This is important to prevent potential contamination and maintain infection control practices. Option B is incorrect because cleaning hands later may lead to the spread of potential contaminants. Option C is unnecessary as starting over is not required if proper hand hygiene is performed. Option D is not sufficient in ensuring proper hygiene after a blood spill, as hand sanitizer may not effectively remove all contaminants.

4. During an assessment, a healthcare professional observes significant tenting of the skin over an older adult client's forearm. What factor should the healthcare professional primarily consider as a cause for this finding?

• A. Thin, parchment-like skin
• B. Loss of adipose tissue
• C. Dehydration
• D. Diminished skin elasticity

Correct answer: C

Rationale: Dehydration is the primary factor to consider in this scenario. Dehydration leads to decreased skin turgor and tenting, where the skin does not return to its normal position when pinched. While thin, parchment-like skin, loss of adipose tissue, and diminished skin elasticity can contribute to skin changes, they are not the primary cause of the significant tenting observed.

5. A client has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status?

• A. Daily weight
• B. Intake and output
• C. Urine specific gravity
• D. Peripheral edema

Correct answer: A

Rationale: Daily weight is the most accurate measure of fluid status in a client with acute renal failure. Fluctuations in weight reflect changes in body fluid volume, including both fluid retention or loss. Intake and output, while important, may not always accurately reflect overall fluid status as it does not account for insensible losses. Urine specific gravity can provide information on urine concentration but does not offer a comprehensive assessment of overall fluid status. Peripheral edema, although a sign of fluid retention, is a more subjective assessment and may not always accurately reflect the client's fluid status like daily weight monitoring does.

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