Nursing Elites

1. What are key signs of fluid overload?

• A. Edema
• B. Hypertension
• C. Shortness of breath
• D. All of the above

Correct answer: D

Rationale: The correct answer is 'D: All of the above.' Edema, hypertension, and shortness of breath are key signs of fluid overload, particularly common in patients with heart failure. Edema refers to the swelling caused by excess fluid trapped in the body's tissues, hypertension can be a result of fluid volume overload, and shortness of breath can occur due to fluid accumulation in the lungs. Therefore, all these signs collectively indicate fluid overload in a patient. Choices A, B, and C are incorrect individually as each alone may not necessarily indicate fluid overload, but when seen together, they strongly suggest fluid volume excess in the body.

2. A healthcare professional is preparing to transfer a client who has had a stroke and is at risk for falling to a rehabilitation facility. Which of the following information should the healthcare professional include in the transfer report?

• A. The client's urination habits.
• B. The client's financial information.
• C. The client's social history.
• D. The client's current level of mobility.

Correct answer: D

Rationale: The client's current level of mobility is essential to be included in the transfer report for the rehabilitation facility to develop an appropriate care plan. Understanding the client's mobility status helps in determining the level of assistance and interventions needed to prevent falls and promote safe rehabilitation. Choices A, B, and C are not directly related to the client's immediate care needs during the transfer to the rehabilitation facility, making them less relevant for the transfer report.

3. Which intervention is most important for a client with chronic heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Limit sodium intake to reduce fluid retention
• D. Restrict daily activity to prevent fatigue

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with chronic heart failure. Monitoring weight helps in detecting fluid retention or fluid loss, which is crucial in managing heart failure. Encouraging fluid intake to prevent dehydration (choice A) may worsen fluid overload in heart failure patients. Limiting sodium intake (choice C) is essential but not the most important intervention compared to monitoring weight. Restricting daily activity (choice D) is not recommended as it is important for clients with heart failure to engage in appropriate levels of physical activity to maintain their overall health.

4. A nurse is reviewing the medical record of a client who is receiving warfarin for atrial fibrillation. Which of the following findings should the nurse report to the provider?

• A. International normalized ratio (INR) of 2.5
• B. Platelet count of 180,000/mm³
• C. Prothrombin time (PT) of 12 seconds
• D. Partial thromboplastin time (PTT) of 30 seconds

Correct answer: C

Rationale: A prothrombin time (PT) of 12 seconds is below the therapeutic range for warfarin and indicates a need for dosage adjustment. The correct answer is C. A normal International normalized ratio (INR) for a client on warfarin therapy is usually between 2.0 to 3.0; therefore, an INR of 2.5 is within the expected range. A platelet count of 180,000/mm³ is within the normal range (150,000 to 450,000/mm³) and does not require immediate reporting. A partial thromboplastin time (PTT) of 30 seconds is also within the normal range (25-35 seconds) and does not indicate a need for urgent action.

5. What is the proper technique for administering an intramuscular (IM) injection?

• A. Locate the injection site and insert at 90 degrees
• B. Insert needle at a 45-degree angle
• C. Massage the site after injection
• D. Insert needle at a 15-degree angle

Correct answer: A

Rationale: The correct technique for administering an intramuscular (IM) injection is to locate the injection site and insert the needle at a 90-degree angle. This angle ensures that the medication is delivered into the muscle for proper absorption. Choice B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Choice C is incorrect as massaging the site after an injection can cause the medication to disperse unevenly. Choice D is incorrect as a 15-degree angle would not reach the muscle layer effectively for an IM injection.

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