Nursing Elites

1. What is the best method to monitor fluid balance in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Monitor blood pressure
• D. Monitor edema

Correct answer: A

Rationale: The best method to monitor fluid balance in a patient receiving diuretics is to monitor daily weight. Daily weighing is a precise way to assess changes in fluid status as it reflects variations in total body water. Monitoring intake and output (choice B) is also important but may not provide as accurate a measurement as daily weight. Monitoring blood pressure (choice C) is essential but does not directly measure fluid balance. Monitoring edema (choice D) is helpful to assess fluid status visually but may not be as sensitive as daily weight measurements in detecting subtle changes in fluid balance.

2. A healthcare professional is preparing to administer an IV bolus of morphine to a client. Which of the following actions should the healthcare professional take first?

• A. Check the client's respiratory rate.
• B. Administer naloxone.
• C. Check the client's pain level.
• D. Assess the client's blood pressure.

Correct answer: A

Rationale: Correct Answer: Checking the client's respiratory rate is the priority before administering morphine because morphine can depress respiration. This action helps the healthcare professional assess the client's baseline respiratory status and detect any potential respiratory depression that may be exacerbated by morphine. Choice B, administering naloxone, is incorrect because naloxone is used as an antidote for opioid overdose and not routinely administered before giving morphine. Choice C, checking the client's pain level, is important but not the first action to take before administering morphine. Choice D, assessing the client's blood pressure, is also important but not the initial priority compared to evaluating respiratory status when preparing to administer morphine.

3. A nurse manager is planning to teach staff about critical pathways. Which of the following information should the nurse include?

• A. Critical pathways have unlimited timeframes for completion.
• B. Critical pathways are designed to decrease health care costs.
• C. Patients follow the critical pathway if variances occur.
• D. Budgets are used to create the critical pathway.

Correct answer: B

Rationale: The correct answer is B. Critical pathways are structured, multi-disciplinary plans of care designed to decrease health care costs and improve outcomes by standardizing and streamlining processes. Choice A is incorrect because critical pathways have specific timeframes for completion. Choice C is incorrect as patients are expected to follow the critical pathway without deviations to achieve optimal outcomes. Choice D is incorrect because budgets do not create critical pathways; rather, they are based on clinical guidelines and best practices.

4. A client with a new diagnosis of heart failure is receiving teaching from a nurse. Which of the following instructions should the nurse include?

• A. Limit sodium intake to 4 grams per day.
• B. Weigh yourself daily to monitor for fluid retention.
• C. Drink 2 liters of water each day.
• D. Increase physical activity gradually.

Correct answer: B

Rationale: The correct answer is B. Weighing oneself daily is crucial in monitoring fluid retention, a key aspect in managing heart failure. This helps in detecting early signs of fluid buildup, prompting timely interventions. Choice A is incorrect as the recommended sodium intake for heart failure clients is usually lower, around 2-3 grams daily. Choice C is incorrect because excessive water intake can worsen fluid retention in heart failure. Choice D is incorrect as clients with heart failure should consult healthcare providers before significantly altering their physical activity levels.

5. A client is taking sucralfate. Which of the following client statements indicates an understanding of the teaching?

• A. I should take this medication 1 hour before meals.
• B. I should take this medication 30 minutes after meals.
• C. I should take this medication only when I have symptoms of heartburn.
• D. I should take this medication with a glass of milk.

Correct answer: A

Rationale: The correct answer is A. Sucralfate is most effective when taken 1 hour before meals to protect the stomach lining. Option B is incorrect because sucralfate should not be taken after meals. Option C is incorrect because sucralfate is typically taken on a regular schedule, not just when symptoms occur. Option D is incorrect because sucralfate should not be taken with milk, as it can interfere with its effectiveness.

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