Nursing Elites

1. What are the complications of untreated fluid overload?

• A. Pulmonary edema and congestive heart failure
• B. Hypertension and electrolyte imbalance
• C. Liver failure and electrolyte imbalance
• D. Pulmonary embolism and dehydration

Correct answer: A

Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.

2. A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?

• A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
• B. Reinforcing teaching with a client who is learning to walk with a quad cane
• C. Reapplying a condom catheter for a client who has urinary incontinence
• D. Applying a sterile dressing to a pressure ulcer

Correct answer: C

Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.

3. A nurse is caring for a client who is at 41 weeks of gestation and is receiving oxytocin for labor induction. The nurse notes early decelerations on the fetal heart rate monitor. Which of the following nursing actions should the nurse take?

• A. Continue to monitor the fetal heart rate.
• B. Stop the oxytocin infusion.
• C. Perform a vaginal examination.
• D. Initiate an amnioinfusion.

Correct answer: A

Rationale: The correct action for early decelerations, which are caused by fetal head compression and are considered normal during labor, is to continue monitoring the fetal heart rate. Early decelerations mirror contractions and usually do not require any intervention. Stopping the oxytocin infusion (Choice B) is not necessary as early decelerations are not typically a cause for concern related to oxytocin. Performing a vaginal examination (Choice C) or initiating an amnioinfusion (Choice D) are unnecessary and not indicated specifically for early decelerations.

4. A nurse is caring for a client who is postoperative following a thyroidectomy and reports tingling and numbness in the hands. The nurse should expect to administer which of the following medications?

• A. Sodium bicarbonate.
• B. Calcium gluconate.
• C. Potassium chloride.
• D. Magnesium sulfate.

Correct answer: B

Rationale: Tingling and numbness in the hands can indicate hypocalcemia, a common complication following a thyroidectomy. Hypocalcemia requires immediate intervention to prevent severe complications like tetany and seizures. Calcium gluconate is the drug of choice for rapidly raising serum calcium levels in hypocalcemic patients. Sodium bicarbonate is not indicated for treating hypocalcemia or related symptoms. Potassium chloride is used to correct potassium imbalances, not calcium. Magnesium sulfate is not the appropriate treatment for hypocalcemia; it is commonly used for conditions like preeclampsia or eclampsia.

5. A client with multiple fractures following a motor-vehicle crash is struggling with opening a milk carton. Which of the following client statements should the nurse recommend a referral to an occupational therapist?

• A. I can't brush my teeth properly
• B. I am so frustrated I can't open my milk carton
• C. I can't hold a pencil
• D. I can't write anymore

Correct answer: B

Rationale: The correct answer is B. Struggling to open a milk carton indicates difficulty with fine motor skills and activities of daily living. This statement suggests a need for assistance from an occupational therapist to improve hand strength, coordination, and independence in performing essential tasks. Choices A, C, and D do not directly relate to the need for occupational therapy services in this context. In contrast, the inability to open a milk carton highlights specific challenges that occupational therapy can address effectively.

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