Nursing Elites

1. What is the best way to assess for fluid overload in a patient with heart failure?

• A. Check daily weight
• B. Check blood pressure
• C. Monitor heart sounds
• D. Assess for jugular vein distention

Correct answer: A

Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.

2. A nurse is planning care for a client who has cirrhosis. Which of the following interventions should the nurse include?

• A. Limit the client's sodium intake to 4 grams per day.
• B. Measure the client's abdominal girth daily.
• C. Monitor the client's urine specific gravity every 12 hours.
• D. Encourage the client to drink 3 liters of fluid per day.

Correct answer: B

Rationale: The correct answer is to measure the client's abdominal girth daily. Measuring abdominal girth helps monitor for ascites, a common complication of cirrhosis. Limiting sodium intake is important in cirrhosis but there is no specific value given, making choice A less precise. Monitoring urine specific gravity is not directly related to cirrhosis management, making choice C incorrect. Encouraging the client to drink 3 liters of fluid per day may not be suitable for all patients with cirrhosis, especially those with fluid restrictions, so choice D is not the most appropriate intervention.

3. A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has a fractured femur and reports feeling short of breath.
• B. A client who is postoperative and has abdominal distention.
• C. A client who is receiving IV fluids and has a temperature of 38.5°C (101.3°F).
• D. A client who has cancer and has been receiving radiation therapy.

Correct answer: A

Rationale: The correct answer is A. A client with a fractured femur and reports feeling short of breath is at risk for a fat embolism, which is a medical emergency. The nurse should assess this client first to rule out this serious complication. Choice B may indicate paralytic ileus, which is important but not immediately life-threatening compared to a fat embolism. Choice C has a fever, which indicates infection but is not as urgent as a potential fat embolism. Choice D, a client receiving radiation therapy, is not experiencing an acute, life-threatening complication that requires immediate assessment compared to a fat embolism.

4. A nurse is assessing a client who is postoperative following a hip arthroplasty. Which of the following findings is the priority for the nurse to report?

• A. Heart rate of 90/min
• B. Blood pressure of 118/76 mm Hg
• C. Warmth and redness in the calf
• D. Pink-tinged urine

Correct answer: C

Rationale: The correct answer is C, warmth and redness in the calf. These symptoms may indicate a deep vein thrombosis (DVT), a serious complication following hip arthroplasty that requires immediate attention. A heart rate of 90/min and blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client and do not indicate an urgent issue. Pink-tinged urine may suggest blood in the urine, which should be monitored but is not as critical as the potential DVT.

5. A client has a new prescription for levothyroxine. Which of the following statements should the nurse include?

• A. Take this medication with food to prevent nausea.
• B. Take this medication in the morning to prevent insomnia.
• C. You should store this medication in the refrigerator.
• D. Take this medication with a full glass of water before breakfast.

Correct answer: D

Rationale: The correct statement the nurse should include is to take levothyroxine with a full glass of water before breakfast. This helps improve absorption and prevents gastrointestinal side effects. Choice A is incorrect because levothyroxine should be taken on an empty stomach. Choice B is incorrect as insomnia is not a common side effect of levothyroxine. Choice C is also incorrect as levothyroxine does not need to be refrigerated.

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