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. A client with a family history of polycystic kidney disease (PKD is being assessed by a nurse. For which clinical manifestations should the nurse assess? (Select all that apply.)

• A. Nocturia
• B. Flank pain
• C. Increased abdominal girth
• D. B & C

Correct answer: D

Rationale: Clients with PKD commonly present with flank pain and increased abdominal girth due to abdominal distention caused by cysts. Bloody urine is also a common symptom due to tissue damage from PKD. Nocturia and dysuria are not typical manifestations of PKD. Constipation is not directly associated with PKD. Therefore, the correct choices are flank pain and increased abdominal girth, making option D the correct answer.

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. A client who has undergone abdominal surgery calls the nurse and reports that she just felt 'something give way' in the abdominal incision. The nurse checks the incision and notes the presence of wound dehiscence. The nurse immediately:

• A. Contacts the physician
• B. Documents the findings
• C. Places the client in a supine position with the legs flat
• D. Covers the abdominal wound with a sterile dressing moistened with sterile saline solution

Correct answer: D

Rationale: In the scenario described, the presence of wound dehiscence indicates a separation of the layers of the surgical incision. The immediate priority for the nurse is to cover the abdominal wound with a sterile dressing moistened with sterile saline solution. This helps to protect the wound from contamination and promotes a moist environment conducive to healing. Contacting the physician (Choice A) is important, but the initial action should be to address the wound. Documenting the findings (Choice B) is necessary but not the immediate priority. Placing the client in a supine position with the legs flat (Choice C) is not indicated in this situation as wound dehiscence requires wound care intervention.

5. A client who is scheduled for cardiac catheterization to rule out coronary occlusion should be informed by the nurse that:

• A. The procedure is performed in a darkened room in the radiology department
• B. It is necessary to lie quietly on a hard x-ray table for about 4 hours
• C. The room is bright and well lit, and it is best to keep the eyes closed
• D. The client may have feelings of warmth or flushing during the procedure

Correct answer: D

Rationale: Before cardiac catheterization, the nurse should inform the client that the procedure is performed in a darkened room in the radiology department, not the operating room. The client should expect to lie still on an x-ray table for the duration of the procedure, not necessarily for about 4 hours. Keeping the eyes closed is not necessary as the room is usually dimly lit. The client may experience sensations of warmth or flushing during the procedure due to catheter passage and dye injection, making choice D the correct answer.

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