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 nurse is caring for a client who has a new diagnosis of hypothyroidism. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Bradycardia.
• C. Tachycardia.
• D. Heat intolerance.

Correct answer: B

Rationale: The correct answer is B: Bradycardia. Bradycardia, or a slow heart rate, is a common finding in clients with hypothyroidism because of the decreased metabolic rate associated with this condition. Weight gain is also a common symptom of hypothyroidism due to the metabolic changes, making choice A incorrect. Tachycardia, or a rapid heart rate, is typically seen in hyperthyroidism, not hypothyroidism, so choice C is incorrect. Heat intolerance is more commonly associated with hyperthyroidism rather than hypothyroidism, making choice D incorrect.

3. A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take?

• A. Confront the client about this behavior
• B. Express sympathy for the client's situation
• C. Speak assertively to the client
• D. Stand within 30 cm (1 ft) of the client when speaking with them

Correct answer: C

Rationale: In this situation, speaking assertively is the most appropriate action for the nurse to take. Confronting the client may escalate the situation further. Expressing sympathy, although important in other contexts, may not be effective in managing aggressive behavior. Standing within close proximity to an aggressive client can compromise the nurse's safety. Therefore, speaking assertively helps to set clear boundaries and manage the situation while ensuring safety in a seclusion room.

4. A nurse is caring for a client who is 4 hours postoperative following an open reduction and internal fixation of the left tibia. Which of the following findings should the nurse report to the provider?

• A. Serous drainage on the dressing
• B. Capillary refill of 2 seconds
• C. Heart rate of 62/min
• D. Left foot is cool to the touch

Correct answer: D

Rationale: The correct answer is D. A cool left foot indicates impaired circulation, which could be a sign of compartment syndrome or impaired blood flow. This finding should be reported to the provider promptly for further evaluation and intervention. Serous drainage on the dressing is expected postoperatively and is not a concerning finding. A capillary refill of 2 seconds is within the normal range (less than 3 seconds is normal), indicating adequate peripheral perfusion. A heart rate of 62/min is also within the normal range for an adult, suggesting no immediate concern related to the surgery.

5. A nurse is performing a dressing change for a client who has a sacral wound using negative pressure wound therapy. Which of the following actions should the nurse take first?

• A. Apply skin preparation to wound edges.
• B. Don sterile gloves.
• C. Normal saline
• D. Determine pain level.

Correct answer: D

Rationale: The correct answer is to determine the pain level first. Assessing the client's pain is crucial before any procedure to ensure their comfort and safety. Applying skin preparation to wound edges (Choice A) may come later in the process after ensuring the client's comfort. Donning sterile gloves (Choice B) is important before directly handling the wound but can follow pain assessment. Normal saline (Choice C) might be used during wound cleansing but is not the initial step in this situation.

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