Nursing Elites

1. During a visit to an 84-year-old woman recovering from hip surgery, the nurse notices signs of confusion and poor skin turgor. The woman mentions she limits water intake to avoid nighttime bathroom trips. The nurse should explain to the woman that:

• A. She will need her medications adjusted and be readmitted for a complete workup.
• B. Limiting fluids can lead to body imbalances causing confusion; perhaps adjusting fluid intake timing is necessary.
• C. Post-surgical confusion is common, and it's safe not to urinate at night.
• D. Confusion after surgery is typical in the elderly due to sleep loss.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid and electrolyte imbalances can manifest with subtle signs like confusion. Limiting fluids can lead to such imbalances, affecting cognitive function. Adjusting the timing of fluid intake can help maintain hydration without causing nighttime disruptions. Choices A, C, and D are incorrect. Choice A suggests unnecessary hospital readmission and medication adjustments without addressing the root cause. Choice C wrongly normalizes the confusion and fails to address the potential issue of fluid restriction. Choice D incorrectly attributes confusion solely to sleep loss without considering the impact of fluid balance.

2. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?

• A. Assess the airway.
• B. Administer prescribed bronchodilators.
• C. Provide oxygen.
• D. Administer prescribed mucolytics

Correct answer: A

Rationale:

3. Which of the following organs does not contribute to fluid output from the body?

• A. Lungs
• B. Skin
• C. Intestine
• D. Lungs, skin, and intestine

Correct answer: D

Rationale: The correct answer is D. All the listed organs (lungs, skin, and intestines) contribute to fluid loss from the body. Lungs contribute to fluid loss through respiration, skin through sweating, and intestines through excretion. Therefore, none of the organs listed in the options retain fluids within the body. Choices A, B, and C are incorrect because all of these organs play a role in fluid output from the body.

4. After teaching a client to increase dietary potassium intake, a nurse assesses the client's understanding. Which dietary meal selection indicates the client correctly understands the teaching?

• A. Toasted English muffin with butter and blueberry jam, and tea with sugar
• B. Two scrambled eggs, a slice of white toast, and a half cup of strawberries
• C. Sausage, one slice of whole wheat toast, half cup of raisins, and a glass of milk
• D. Bowl of oatmeal with brown sugar, a half cup of sliced peaches, and coffee

Correct answer: C

Rationale: Choice C is the correct answer as it includes foods high in potassium, such as raisins, whole wheat toast, and milk. Potassium is essential for various bodily functions, including maintaining proper heart and muscle function. Choices A, B, and D do not contain significant sources of potassium. Choice A consists mainly of carbohydrates and sugar, choice B focuses on protein and carbohydrates, and choice D provides carbohydrates and some fruit but lacks high-potassium options like in choice C.

5. The chief mechanism for maintaining fluid balance is to:

• A. adjust fluid intake so it equals fluid output.
• B. adjust fluid intake so it is slightly above fluid output.
• C. adjust fluid output so it equals fluid input.
• D. adjust fluid intake so it is slightly below fluid output.

Correct answer: C

Rationale: The correct answer is C: 'adjust fluid output so it equals fluid input.' Maintaining fluid balance involves ensuring that the amount of fluid lost through processes like urination, sweating, and respiration equals the amount of fluid taken in. This ensures that the body stays properly hydrated. Choices A, B, and D are incorrect because they do not focus on the balance between fluid input and output, which is crucial for maintaining proper fluid balance. By adjusting fluid output to equal fluid input, the body can regulate hydration levels effectively, preventing dehydration or overhydration.

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