Nursing Elites

1. The nurse is caring for a client with a diagnosis of pneumonia who has been febrile for 24 hours. Which data is most important for the nurse to obtain in determining the client's fluid status?

• A. Daily intake and output
• B. Skin turgor
• C. Daily weight
• D. Vital signs every 4 hours

Correct answer: C

Rationale: Daily weight is the most important data for the nurse to obtain in determining the client's fluid status in this scenario. During febrile episodes, assessing daily weight is crucial as it can indicate fluid retention or loss. While monitoring intake and output is important for assessing fluid balance, daily weight provides a more comprehensive picture of fluid status over time. Skin turgor is more indicative of hydration status than overall fluid status, and vital signs, although essential, do not directly assess fluid status as effectively as daily weight.

2. A male client tells the nurse, 'I am so stressed because I am expected to achieve excellence in everything. My job, my marriage, and my children must be perfect!' Which coping response should the nurse recognize that the client is using?

• A. Repression
• B. Sublimation
• C. Rationalization
• D. Displacement

Correct answer: C

Rationale: The correct answer is C: Rationalization. Rationalization is a defense mechanism where the client justifies their stress and need for perfection by creating logical explanations or excuses. In this case, the client is rationalizing their stress by believing that everything in their life must be perfect. Repression (choice A) involves unconsciously blocking out thoughts or feelings. Sublimation (choice B) is redirecting unacceptable impulses into socially acceptable activities. Displacement (choice D) involves transferring emotions from one target to another.

3. Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?

• A. Risk for imbalanced body temperature
• B. Excess fluid volume
• C. Fatigue
• D. Ineffective Tissue Perfusion

Correct answer: D

Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.

4. A client who has a new prescription for warfarin (Coumadin) asks the nurse how the medication works. What explanation should the nurse provide?

• A. It dissolves blood clots
• B. It prevents the blood from clotting
• C. It thins the blood
• D. It decreases the risk of infection

Correct answer: B

Rationale: The correct answer is B: 'It prevents the blood from clotting.' Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors in the liver, thereby preventing the formation of blood clots. Choice A is incorrect because warfarin does not dissolve existing blood clots but prevents new ones from forming. Choice C is partially correct but not as specific as choice B in explaining how warfarin works. Choice D is unrelated to the mechanism of action of warfarin and is incorrect.

5. The nurse assesses a client who is receiving an infusion of 5% dextrose in water with 20 mEq of potassium chloride. The client has oliguria and a serum potassium level of 6.5 mEq/L. What action should the nurse implement first?

• A. Notify the healthcare provider of the laboratory results
• B. Decrease the rate of the IV infusion
• C. Stop the infusion
• D. Administer sodium polystyrene sulfonate (Kayexalate)

Correct answer: C

Rationale: The correct action for the nurse to implement first is to stop the infusion. Stopping the infusion is crucial to prevent further potassium from being administered, which can exacerbate the client's hyperkalemia. Notifying the healthcare provider of the laboratory results (Choice A) can be done after taking immediate action to stop the infusion. Decreasing the rate of the IV infusion (Choice B) may not be sufficient to address the high potassium level quickly. Administering sodium polystyrene sulfonate (Kayexalate) (Choice D) is not the initial action for managing hyperkalemia; stopping the potassium infusion takes precedence.

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