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 assessing a school-age child with a urinary tract infection. Which symptom should the nurse expect?

• A. Periorbital edema.
• B. Decreased frequency of urination.
• C. Enuresis.
• D. Diarrhea.

Correct answer: C

Rationale: Enuresis is a common symptom of urinary tract infections in school-age children. It is often a presenting symptom due to irritation of the bladder. Periorbital edema (Choice A) is more indicative of conditions like nephrotic syndrome or renal disorders. Decreased frequency of urination (Choice B) is not typically associated with urinary tract infections. Diarrhea (Choice D) is not a common symptom of urinary tract infections but may occur due to other reasons like gastrointestinal infections.

3. A nurse is caring for a client who has acute pancreatitis. Which of the following interventions should the nurse take?

• A. Encourage oral intake of clear liquids
• B. Administer an antiemetic before meals
• C. Insert a nasogastric tube for suction
• D. Place the client in a supine position

Correct answer: C

Rationale: In acute pancreatitis, the gastrointestinal tract needs to rest to reduce pancreatic enzyme secretion. Inserting a nasogastric tube for suction helps decompress the stomach and reduce stimulation of the pancreas. Encouraging oral intake of clear liquids (Choice A) or administering an antiemetic before meals (Choice B) may aggravate the condition by stimulating the pancreas. Placing the client in a supine position (Choice D) may not directly address the underlying issue of reducing pancreatic stimulation.

4. A healthcare provider is assessing a client who has COPD and is receiving oxygen therapy at 2 L/min via nasal cannula. Which of the following findings should the provider report?

• A. Oxygen saturation of 95%.
• B. Productive cough with clear sputum.
• C. Respiratory rate of 22/min.
• D. Client reports dyspnea.

Correct answer: D

Rationale: The correct answer is D. Dyspnea in a client with COPD receiving oxygen should be reported as it may indicate worsening respiratory status. Oxygen saturation of 95% is within the expected range for a client receiving oxygen therapy and does not require immediate reporting. A productive cough with clear sputum is a common symptom in clients with COPD and does not necessarily warrant urgent reporting. A respiratory rate of 22/min is also within normal limits and does not raise immediate concerns in this scenario.

5. A client sustained a major burn over 20% of the body. What intervention should the nurse implement to meet the client's nutritional needs?

• A. Keep track of calorie intake for food and beverages.
• B. Provide a low-protein, high-carbohydrate diet.
• C. Schedule meals at 6-hour intervals.
• D. Provide a high-protein, high-calorie diet.

Correct answer: D

Rationale: The correct answer is to provide a high-protein, high-calorie diet for a client with major burns. This type of diet is essential to support healing and recovery. High-protein intake is crucial as it helps in tissue repair and wound healing, while high-calorie intake is necessary to meet the increased metabolic demands of the body during the healing process. Keeping track of calorie intake (Choice A) is important but doesn't address the specific needs of a burn patient. Providing a low-protein, high-carbohydrate diet (Choice B) is not suitable for burn patients as they require adequate protein for wound healing. Scheduling meals at 6-hour intervals (Choice C) may be helpful for maintaining a consistent eating schedule, but it is not as crucial as providing the correct high-protein, high-calorie diet.

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