Nursing Elites

1. During an assessment on a patient brought to the emergency department for treatment for dehydration, the nurse notes a respiratory rate of 26 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 86/50 mm Hg, and a temperature of 39.5° C. The patient becomes dizzy when transferred from the wheelchair to a bed. The nurse observes cool, clammy skin. Which diagnosis does the nurse suspect?

• A. Fluid volume deficit (FVD)
• B. Fluid volume excess (FVE)
• C. Mild extracellular fluid (ECF) deficit
• D. Renal failure

Correct answer: A

Rationale: The nurse should suspect Fluid Volume Deficit (FVD) in this patient. Signs of FVD include elevated temperature, tachycardia, tachypnea, hypotension, orthostatic hypotension, and cool, clammy skin, which align with the patient's assessment findings. Choices B, C, and D are incorrect. Fluid Volume Excess (FVE) typically presents with bounding pulses, elevated blood pressure, dyspnea, and crackles. Mild extracellular fluid (ECF) deficit usually manifests as thirst. Renal failure commonly results in Fluid Volume Excess (FVE) rather than Fluid Volume Deficit (FVD).

2. After teaching a client with nephrotic syndrome and a normal glomerular filtration rate, the nurse assesses the client’s understanding. Which statement made by the client indicates a correct understanding of the nutritional therapy for this condition?

• A. I must decrease my intake of fat.
• B. I will increase my intake of protein.
• C. A decreased intake of carbohydrates will be required.
• D. An increased intake of vitamin C is necessary.

Correct answer: B

Rationale: In nephrotic syndrome, there is significant renal loss of protein leading to hypoalbuminemia and edema formation. If glomerular filtration is normal or near normal, increased protein loss should be matched by an increased intake of protein. Therefore, the correct statement indicating a correct understanding of the nutritional therapy for this condition is increasing protein intake. Decreasing fat, decreasing carbohydrates, or increasing vitamin C intake is not necessary for addressing the underlying issues associated with nephrotic syndrome.

3. The patient weighs 75 kg and is receiving IV fluids at a rate of 50 mL/hour, having consumed 100 mL orally in the past 24 hours. What action will the nurse take?

• A. Contact the provider to ask about increasing the IV rate to 90 mL/hour.
• B. Discuss with the provider the need to increase the IV rate to 150 mL/hour.
• C. Encourage the patient to drink more water so the IV can be discontinued.
• D. Instruct the patient to drink 250 mL of water every 8 hours.

Correct answer: A

Rationale: The recommended daily fluid intake for adults is 30 to 40 mL/kg/day. For a patient weighing 75 kg, the minimum intake should be 2250 mL/day. The patient is currently receiving 1200 mL IV and 100 mL orally, totaling 1300 mL. Increasing the IV rate to 90 mL/hour would provide a total of 2160 mL, which could meet the patient's needs if oral intake continues. Option B suggests increasing the IV rate to 150 mL/hour, resulting in an excessive fluid intake of 3600 mL/day, surpassing the recommended amount. Option C, encouraging increased fluid intake, is not recommended as the patient is already struggling with fluid intake. Option D, instructing the patient to drink 250 mL of water every 8 hours, would still fall short of the required fluid intake of 2250 mL/day.

4. To assess the quality of an adult client's pain, what approach should the nurse use?

• A. Observe body language and movement.
• B. Ask the client to describe the pain.
• C. Identify effective pain relief measures.
• D. Provide a numeric pain scale.

Correct answer: B

Rationale: The correct answer is to ask the client to describe the pain. This approach allows the nurse to gather subjective information directly from the client, such as the quality, intensity, location, and factors that aggravate or alleviate the pain. Observing body language and movement (Choice A) can provide additional cues but may not fully capture the client's pain experience. Identifying effective pain relief measures (Choice C) and providing a numeric pain scale (Choice D) are important aspects of pain management but do not directly assess the quality of the client's pain.

5. After educating a client with stress incontinence, the nurse assesses the client’s understanding. Which statement made by the client indicates a need for additional teaching?

• A. I will limit my total intake of fluids.
• B. I must avoid drinking alcoholic beverages.
• C. I must avoid drinking caffeinated beverages.
• D. I shall try to lose about 10% of my body weight.

Correct answer: A

Rationale: The correct answer is A. Limiting fluids can worsen stress incontinence by concentrating urine and irritating tissues, leading to increased incontinence. Adequate hydration is important to maintain bladder health and function. Choices B and C are correct as avoiding alcoholic and caffeinated beverages can help reduce bladder irritation. Choice D is also correct as losing about 10% of body weight can help reduce intra-abdominal pressure, which is beneficial in managing stress incontinence.

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