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. Assessment of the diabetic client for common complications should include examination of the:

• A. Abdomen.
• B. Lymph glands.
• C. Pharynx.
• D. Eyes.

Correct answer: D

Rationale: The correct answer is D: Eyes. Diabetic clients are at high risk of developing complications such as diabetic retinopathy, making regular eye examinations crucial. Assessing the eyes helps in early detection and management of diabetic eye diseases. Choices A, B, and C are incorrect because while they may be relevant in certain assessments, they are not commonly associated with complications specific to diabetes. Examination of the abdomen, lymph glands, and pharynx are not typically part of routine assessments for common complications in diabetic clients.

3. A client with cholelithiasis is admitted with jaundice due to obstruction of the common bile duct. Which finding is most important for the nurse to report to the healthcare provider?

• A. Distended, hard, and rigid abdomen
• B. Clay-colored stool
• C. Radiating sharp pain in the right shoulder
• D. Bile-stained emesis

Correct answer: A

Rationale: The most important finding for the nurse to report to the healthcare provider in a client with cholelithiasis and jaundice due to common bile duct obstruction is a distended, hard, and rigid abdomen. These signs may indicate a possible surgical emergency, such as a complication like gallbladder perforation or peritonitis, which require immediate intervention. Clay-colored stool is associated with obstructive jaundice but does not indicate an acute surgical emergency. Radiating sharp pain in the right shoulder (referred pain from the diaphragm) and bile-stained emesis may also be seen in cholelithiasis but are not as urgent as a distended, hard, and rigid abdomen.

4. A client is receiving a continuous IV infusion of heparin for the treatment of deep vein thrombosis. The client’s activated partial thromboplastin time (aPTT) level is 80 seconds. The client’s baseline before the initiation of therapy was 30 seconds. Which action does the nurse anticipate is needed?

• A. Shutting off the heparin infusion
• B. Increasing the rate of the heparin infusion
• C. Decreasing the rate of the heparin infusion
• D. Leaving the rate of the heparin infusion as is

Correct answer: C

Rationale: The nurse needs to decrease the rate of the heparin infusion. The therapeutic dose of heparin for the treatment of deep vein thrombosis is designed to keep the aPTT between 1.5 and 2.5 times normal. With the client's aPTT level elevated to 80 seconds from a baseline of 30 seconds, it indicates that the current rate of heparin infusion is too high. Lowering the rate of infusion is necessary to bring the aPTT within the desired therapeutic range. Choices A, B, and D are incorrect because shutting off the infusion, increasing the rate, or leaving it as is would not address the elevated aPTT level and may lead to complications.

5. A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding should prompt immediate action by the nurse?

• A. Blood pressure of 76/58 mm Hg
• B. Sodium level of 138 mEq/L
• C. Potassium level of 5.5 mEq/L
• D. Pulse rate of 90 beats/min

Correct answer: A

Rationale: The correct answer is A: Blood pressure of 76/58 mm Hg. In a client undergoing continuous venovenous hemofiltration (CVVH), hypotension can be a significant concern if replacement fluid does not adequately maintain blood pressure. The nurse should take immediate action to address hypotension to prevent further complications. The sodium level of 138 mEq/L is within normal range, and a potassium level of 5.5 mEq/L, while slightly elevated, may be expected in a patient with acute kidney injury. A pulse rate of 90 beats/min falls within the normal range and does not typically require immediate intervention in this context.

Similar Questions