Nursing Elites

1. A nurse is teaching a client who has heart failure about managing fluid intake. Which of the following instructions should the nurse include?

• A. Drink 2 liters of water per day.
• B. You should restrict your fluid intake to 1 liter per day.
• C. You can drink as much fluid as you want throughout the day.
• D. Limit your fluid intake to 3 liters per day.

Correct answer: B

Rationale: The correct answer is B: "You should restrict your fluid intake to 1 liter per day." Clients with heart failure should limit their fluid intake to prevent fluid overload, which can worsen their condition. Choice A is incorrect because 2 liters of water per day may be excessive for someone with heart failure. Choice C is incorrect as unlimited fluid intake is not suitable for individuals with heart failure. Choice D is also incorrect as 3 liters per day may be too much fluid for a client with heart failure.

2. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse should identify that which of the following findings is a manifestation of opioid toxicity?

• A. Bradypnea.
• B. Tachycardia.
• C. Hypertension.
• D. Diaphoresis.

Correct answer: A

Rationale: Corrected Rationale: Bradypnea, or slow breathing, is a common sign of opioid toxicity. When a client is experiencing opioid toxicity, the respiratory system is usually the most affected, leading to a decrease in the respiratory rate (bradypnea). Tachycardia (increased heart rate), hypertension (high blood pressure), and diaphoresis (excessive sweating) are not typical manifestations of opioid toxicity. Therefore, the correct answer is bradypnea.

3. What is the most important nursing intervention for a patient with a suspected pulmonary embolism?

• A. Administer anticoagulants
• B. Administer oxygen
• C. Reposition the patient
• D. Monitor oxygen saturation

Correct answer: A

Rationale: The most important nursing intervention for a patient with a suspected pulmonary embolism is to administer anticoagulants. Anticoagulants help prevent further clot formation in the patient's blood vessels, reducing the risk of complications such as worsening of the pulmonary embolism or development of new clots. Administering oxygen (Choice B) may be necessary to support the patient's oxygenation, but anticoagulants take precedence as they target the underlying cause of the pulmonary embolism. Repositioning the patient (Choice C) and monitoring oxygen saturation (Choice D) are important aspects of patient care but are not the primary intervention for a suspected pulmonary embolism.

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

• A. Check the central line dressing daily
• B. Monitor for signs of redness
• C. Check for abnormal breath sounds
• D. Monitor temperature

Correct answer: A

Rationale: Correct answer: A. Checking the central line dressing daily is crucial to monitor for signs of infection around the insertion site. This practice helps in early detection of any changes such as redness, swelling, or discharge, which are indicators of a potential infection. Monitoring for signs of redness (choice B) is limited as redness alone may not always indicate an infection; other symptoms like discharge and tenderness should also be observed. Checking for abnormal breath sounds (choice C) is not directly related to monitoring central line infections. Monitoring temperature (choice D) is important for detecting systemic signs of infection but may not specifically indicate an infection related to the central line site.

5. A nurse is assessing a client who is 1 day postoperative following hip replacement surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Serosanguineous drainage on the surgical dressing
• C. Blood pressure of 118/76 mm Hg
• D. Urine output of 40 mL/hr

Correct answer: D

Rationale: The correct answer is D: Urine output of 40 mL/hr. A low urine output may indicate kidney complications, such as acute kidney injury, which is a critical finding postoperatively. The nurse should report this immediately to the provider for further evaluation and management. Choices A, B, and C are within normal limits for a client who is 1 day postoperative following hip replacement surgery and do not indicate immediate concerns that require reporting to the provider.

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