Nursing Elites

1. What is the best way to monitor fluid balance in a patient with kidney disease?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Check urine output

Correct answer: A

Rationale: The correct answer is to monitor daily weight. This method is the most accurate way to assess fluid balance in patients with kidney disease. Daily weight monitoring can detect even small changes in fluid balance, such as fluid retention or loss, which may not be evident through other methods. Monitoring input and output (choice B) is also important but may not provide a complete picture of fluid balance as it doesn't consider factors like insensible losses. Checking for edema (choice C) is a sign of fluid retention but may not always be present or may be difficult to assess accurately. Checking urine output (choice D) is important but may not reflect the overall fluid balance status of the patient.

2. Which electrolyte imbalance is commonly seen in patients receiving furosemide?

• A. Hypokalemia
• B. Hypercalcemia
• C. Hyponatremia
• D. Hyperkalemia

Correct answer: A

Rationale: The correct answer is A: Hypokalemia. Furosemide is a loop diuretic that can lead to potassium loss, resulting in hypokalemia. This electrolyte imbalance necessitates close monitoring to prevent complications such as cardiac arrhythmias. Choices B, C, and D are incorrect. Hypercalcemia is not a common side effect of furosemide. Hyponatremia is more commonly associated with other medications like thiazide diuretics. Hyperkalemia is the opposite electrolyte imbalance and is not typically seen with furosemide use.

3. A nurse is caring for a client who is receiving oxytocin to augment labor. The client's contractions are occurring every 2 minutes with a duration of 90 seconds. Which of the following actions should the nurse take?

• A. Increase the oxytocin infusion.
• B. Maintain the oxytocin infusion.
• C. Discontinue the oxytocin infusion.
• D. Provide reassurance to the client.

Correct answer: C

Rationale: The correct action for the nurse to take in this situation is to discontinue the oxytocin infusion. With contractions occurring every 2 minutes and lasting 90 seconds, this pattern indicates hyperstimulation, which can be harmful to the fetus. Discontinuing the oxytocin infusion is essential to prevent further harm. Increasing the oxytocin infusion would exacerbate the situation, maintaining it would continue the risk, and providing reassurance to the client, although important, does not address the need for immediate action to ensure the safety of the fetus.

4. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?

• A. Dry mucous membranes
• B. Polyuria
• C. Epistaxis
• D. Diarrhea

Correct answer: C

Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.

5. A nurse is developing a care plan for a client with Alzheimer's disease. Which of the following interventions should the nurse include?

• A. Provide reality orientation throughout the day.
• B. Limit the client's choices to prevent decision fatigue.
• C. Encourage the client to participate in group therapy.
• D. Engage the client in sensory stimulation activities.

Correct answer: A

Rationale: The correct intervention the nurse should include in the care plan for a client with Alzheimer's disease is to provide reality orientation throughout the day. Reality orientation involves helping clients with Alzheimer's disease stay connected to the present, reducing confusion and disorientation. This intervention can help the client maintain a sense of time, place, and person. Choices B, C, and D are incorrect because limiting choices may lead to frustration, group therapy may not always be suitable for clients with Alzheimer's disease, and sensory stimulation activities may not address the core issue of disorientation in Alzheimer's disease.

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