Nursing Elites

1. A 70-year-old client is admitted to the hospital after 24 hours of acute diarrhea. To determine fluid status, which initial data is most important for the nurse to obtain?

• A. Usual and current weight
• B. Color and amount of urine
• C. Number and frequency of stools
• D. Intake and output 24 hours prior to admission

Correct answer: A

Rationale: The correct answer is A: Usual and current weight. Weight changes are the most direct indicator of fluid status in a patient with acute diarrhea. Monitoring weight loss or gain can provide crucial information about fluid balance. Option B, color and amount of urine, though important for assessing renal function, is not as direct an indicator of fluid status as weight. Option C, number and frequency of stools, is relevant for assessing the severity of diarrhea but does not provide direct information on fluid status. Option D, intake and output 24 hours prior to admission, does not reflect the current fluid status and may not be accurate in a rapidly changing condition like acute diarrhea.

2. Following the evacuation of a subdural hematoma, an older adult develops an infection. The client is transferred to the neuro intensive care unit with a temperature of 101.8 F (39.3 C) axillary, pulse of 180 beats/minute, and a blood pressure of 90/60 mmHg. What is the priority intervention to include in this client’s plan of care?

• A. Confusion
• B. Check neuro vital signs every 4 hours.
• C. Maintain intravenous access.
• D. Keep the suture line clean and dry.

Correct answer: C

Rationale: The priority intervention for the client in this scenario is to maintain intravenous (IV) access. Given the client's condition with infection, elevated temperature, tachycardia, and hypotension, it is crucial to ensure IV access for administering antibiotics, fluids, and other medications promptly. This can help manage the infection, stabilize hemodynamics, and support the client's hydration and medication needs. Checking neuro vital signs, although important, is secondary to addressing the immediate need for IV access. Keeping the suture line clean and dry is important for wound care but not the priority when dealing with a systemic infection and hemodynamic instability.

3. A client with chronic alcoholism is admitted with a decreased serum magnesium level. Which snack option should the nurse recommend to this client?

• A. Cheddar cheese and crackers
• B. Carrot and celery sticks
• C. Beef bologna sausage slices
• D. Dry roasted almonds

Correct answer: D

Rationale: Dry roasted almonds are the most suitable snack option for a client with chronic alcoholism and a decreased serum magnesium level because they are high in magnesium. Magnesium is essential in addressing the deficiency. Cheddar cheese and crackers (Choice A) do not contain as much magnesium as almonds. Carrot and celery sticks (Choice B) are healthy choices but do not provide a significant amount of magnesium. Beef bologna sausage slices (Choice C) are not a good choice as processed meats are not rich in magnesium.

4. A 12-year-old client who had an appendectomy two days ago is receiving 0.9% normal saline at 50 ml/hour. The client’s urine specific gravity is 1.035. What action should the nurse implement?

• A. Encourage popsicles and fluids of choice
• B. Evaluate postural blood pressure measurements
• C. Obtain a specimen for urinalysis
• D. Assess bowel sounds in all quadrants

Correct answer: A

Rationale: Encouraging fluids helps address dehydration and potentially high urine specific gravity, which is often related to inadequate fluid intake. In this scenario, the client may be at risk of dehydration due to the appendectomy and the high urine specific gravity. Encouraging popsicles and fluids of choice can help increase fluid intake and improve hydration status. The other options are not the priority at this time. Postural blood pressure measurements may be relevant for assessing fluid status but are not the immediate action needed. Obtaining a specimen for urinalysis and assessing bowel sounds are not the priority actions based on the client's condition.

5. A client with a BMI of 60.2 kg/m² is admitted to the intensive care unit 3 weeks after gastric bypass with gastric rupture and impending multiple organ dysfunction syndrome (MODS). What should the nurse prepare to implement first?

• A. Mechanical ventilation
• B. Platelet transfusion
• C. Loop diuretic therapy
• D. Cyanocobalamin administration

Correct answer: A

Rationale: In this critical situation with gastric rupture and impending MODS, the priority intervention should be mechanical ventilation. This client is at risk of respiratory compromise due to the severity of the condition. Platelet transfusion (Choice B) is not the priority as there is no indication of significant bleeding. Loop diuretic therapy (Choice C) and cyanocobalamin administration (Choice D) are not the immediate priorities in this scenario and would not address the urgent need for respiratory support.

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