Nursing Elites

1. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?

• A. Glasgow Coma Scale score of 15
• B. Blood drainage on the initial dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.

2. A nurse is caring for a client who has a new diagnosis of hypothyroidism. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Bradycardia.
• C. Tachycardia.
• D. Heat intolerance.

Correct answer: B

Rationale: The correct answer is B: Bradycardia. Bradycardia, or a slow heart rate, is a common finding in clients with hypothyroidism because of the decreased metabolic rate associated with this condition. Weight gain is also a common symptom of hypothyroidism due to the metabolic changes, making choice A incorrect. Tachycardia, or a rapid heart rate, is typically seen in hyperthyroidism, not hypothyroidism, so choice C is incorrect. Heat intolerance is more commonly associated with hyperthyroidism rather than hypothyroidism, making choice D incorrect.

3. How should a healthcare professional monitor a patient with a central line for infection?

• A. Monitor the dressing site daily
• B. Check for redness and swelling
• C. Monitor for fever
• D. Flush the central line

Correct answer: A

Rationale: Monitoring the dressing site daily is crucial for detecting early signs of infection in patients with central lines. Checking for redness and swelling (choice B) is important but may indicate a more advanced stage of infection. Monitoring for fever (choice C) can also be a sign of infection, but it is a later manifestation. Flushing the central line (choice D) is necessary for maintaining patency but does not directly monitor for infection.

4. What is the best method to monitor fluid balance in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Monitor blood pressure
• D. Monitor edema

Correct answer: A

Rationale: The best method to monitor fluid balance in a patient receiving diuretics is to monitor daily weight. Daily weighing is a precise way to assess changes in fluid status as it reflects variations in total body water. Monitoring intake and output (choice B) is also important but may not provide as accurate a measurement as daily weight. Monitoring blood pressure (choice C) is essential but does not directly measure fluid balance. Monitoring edema (choice D) is helpful to assess fluid status visually but may not be as sensitive as daily weight measurements in detecting subtle changes in fluid balance.

5. A client with chronic kidney disease is being taught about dietary modifications by a nurse. Which of the following foods should the nurse instruct the client to avoid?

• A. Grilled chicken.
• B. Fresh fruit.
• C. White bread.
• D. Cheddar cheese.

Correct answer: D

Rationale: Cheddar cheese is high in phosphorus, which should be avoided by clients with chronic kidney disease. Fresh fruit is generally a healthy choice unless the client needs to limit potassium intake. Grilled chicken is a good protein source for clients with chronic kidney disease. White bread is low in phosphorus and can be included in the diet of clients with kidney disease unless they need to watch their carbohydrate intake.

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