Nursing Elites

1. Which of the following is the best indicator of fluid balance in a patient with heart failure?

• A. Daily weight measurements.
• B. Monitoring intake and output.
• C. Assessing skin turgor.
• D. Checking for peripheral edema.

Correct answer: A

Rationale: Daily weight measurements are the best indicator of fluid balance in a patient with heart failure. Changes in weight reflect fluid retention or loss more accurately than other methods. Monitoring intake and output (choice B) is essential but may not provide a comprehensive picture of fluid status. Skin turgor (choice C) and checking for peripheral edema (choice D) are more indicative of dehydration and fluid overload, respectively, rather than overall fluid balance.

2. A client is receiving Cilostazol (Pletal) for peripheral arterial disease causing intermittent claudication. The nurse determines this medication is effective when the client reports which of the following?

• A. I am having fewer aches and pains.
• B. I do not have headaches anymore.
• C. I am able to walk further without leg pain.
• D. My toes are turning grayish black in color.

Correct answer: C

Rationale: The correct answer is C. Cilostazol improves blood flow to the muscles, which helps alleviate symptoms of intermittent claudication. An improvement in walking distance without leg pain indicates the effectiveness of the medication. Choices A and B are not directly related to the expected outcome of Cilostazol therapy for intermittent claudication. Choice D is concerning for a potential adverse effect and should be reported to the healthcare provider immediately.

3. In a patient with anemia, which of the following is the primary symptom to assess?

• A. Fever.
• B. Chest pain.
• C. Shortness of breath.
• D. Muscle cramps.

Correct answer: C

Rationale: The correct answer is C: Shortness of breath. In a patient with anemia, the primary symptom to assess is shortness of breath. Anemia leads to a reduced oxygen-carrying capacity of the blood, resulting in tissues not receiving adequate oxygen. This can manifest as shortness of breath, especially during physical exertion. Fever (Choice A), chest pain (Choice B), and muscle cramps (Choice D) are not typically primary symptoms of anemia. Fever may suggest an infection, chest pain can be indicative of cardiac issues, and muscle cramps may be related to electrolyte imbalances or neuromuscular disorders.

4. After an endotracheal tube is placed in a client who experienced sudden onset of respiratory distress, what should the nurse do?

• A. Secure the tube in place with tape
• B. Order a chest x-ray for the client
• C. Document the depth of tube insertion
• D. Auscultate both lungs for breath sounds

Correct answer: D

Rationale: After endotracheal tube insertion, the nurse should auscultate both lungs for the presence of breath sounds. This step helps confirm proper tube placement and adequate ventilation. Auscultation of breath sounds is crucial to ensure that the tube is correctly positioned in the trachea and not in the esophagus. While securing the tube with tape is important, it is not the immediate priority after insertion. Ordering a chest x-ray may be necessary but is not the first action to take immediately post-intubation. Documenting the depth of tube insertion is important but ensuring proper ventilation through auscultation takes precedence.

5. Which food is most important to encourage a client with osteomalacia to include in a daily diet?

• A. Fortified milk and cereals
• B. Citrus fruits and juices
• C. Green leafy vegetables
• D. Red meats and eggs

Correct answer: A

Rationale: The correct answer is A: Fortified milk and cereals. Osteomalacia is a condition caused by a deficiency in vitamin D. Fortified milk and cereals are rich sources of vitamin D, which is essential for managing osteomalacia. Citrus fruits and juices (choice B) are high in vitamin C, but vitamin D is the primary concern for osteomalacia. Green leafy vegetables (choice C) are good sources of various nutrients but not the main focus for managing osteomalacia. Red meats and eggs (choice D) are good sources of protein and other nutrients but are not as critical as fortified milk and cereals for addressing vitamin D deficiency in osteomalacia.

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