Nursing Elites

1. A nurse is assessing four clients for fluid balance. Which of the following clients is exhibiting manifestations of dehydration?

• A. A client who has a urine specific gravity of 1.010.
• B. A client who has a weight gain of 2.2 kg (2 lb) in 24 hr.
• C. A client who has a hematocrit of 45%.
• D. A client who has a temperature of 39°C (102°F).

Correct answer: D

Rationale: The correct answer is D because an elevated temperature is a common manifestation of dehydration. Choices A, B, and C are not indicative of dehydration. A urine specific gravity of 1.010 is within normal range, weight gain suggests fluid overload, and a hematocrit of 45% is also within normal limits and not specifically related to dehydration.

2. A postpartum client with AB negative blood whose newborn is B positive requires what intervention?

• A. Administer Rh immune globulin within 72 hours of delivery
• B. Administer Rh immune globulin at the 6-week postpartum visit
• C. No Rh immune globulin is needed since this is the second pregnancy
• D. Both mother and baby need Rh immune globulin

Correct answer: A

Rationale: The correct intervention is to administer Rh immune globulin within 72 hours of delivery. This is essential to prevent the mother from forming antibodies against Rh-positive blood, which could cause complications in future pregnancies. Choice B is incorrect as the administration should be immediate postpartum. Choice C is incorrect as Rh immune globulin is needed for each Rh-incompatible pregnancy. Choice D is incorrect as only the mother, who is Rh-negative, needs Rh immune globulin.

3. A client is being treated with thiazide diuretics. What should the nurse monitor regularly?

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

Correct answer: B

Rationale: Thiazide diuretics are known to cause hypokalemia by increasing potassium excretion in the urine. Therefore, the nurse should monitor the client for low potassium levels. Hyperkalemia (Choice A) is not typically associated with thiazide diuretics. Hyponatremia (Choice C) is more commonly linked with thiazide diuretics due to increased sodium excretion. Hypoglycemia (Choice D) is not a usual concern when a client is receiving thiazide diuretics.

4. A nurse enters a client's room and sees smoke coming from the trash can. Which of the following actions should the nurse take first?

• A. Close the window
• B. Evacuate the room
• C. Call the fire department
• D. Attempt to extinguish the fire

Correct answer: B

Rationale: The correct answer is to evacuate the room first. In a fire situation, the priority is safety, following the RACE protocol: Rescue, Alarm, Contain, Extinguish. Evacuating the room ensures the safety of both the client and the nurse. Closing the window (Choice A) can wait until after evacuation when there is no immediate danger. Calling the fire department (Choice C) is important but comes after ensuring personal safety and evacuating. Attempting to extinguish the fire (Choice D) is not recommended as it can put the nurse and the client at risk; firefighting should be left to professionals.

5. A nurse is providing education to a client about a new prescription for digoxin. Which of the following should be included?

• A. Monitor for increased heart rate
• B. Take the medication at the same time every day
• C. It should be stopped abruptly
• D. Avoid potassium-rich foods

Correct answer: B

Rationale: The correct answer is B: 'Take the medication at the same time every day.' Clients should take digoxin at the same time each day to maintain consistent therapeutic levels, enhancing the drug's effectiveness and minimizing fluctuations in blood concentration. Choice A is incorrect because digoxin, as a medication, may actually help in controlling the heart rate. Choice C is incorrect as digoxin should never be stopped abruptly due to the risk of rebound effects and worsening of the condition. Choice D is unrelated to digoxin therapy, as it is more relevant to medications like potassium-sparing diuretics.

Similar Questions