Nursing Elites

1. How should a healthcare provider assess a patient for fluid overload?

• A. Monitor weight and assess for shortness of breath
• B. Auscultate lung sounds and monitor blood pressure
• C. Assess for edema in the extremities
• D. Assess for jugular venous distension

Correct answer: A

Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.

2. What are the complications of untreated fluid overload?

• A. Pulmonary edema and congestive heart failure
• B. Hypertension and electrolyte imbalance
• C. Liver failure and electrolyte imbalance
• D. Pulmonary embolism and dehydration

Correct answer: A

Rationale: Corrected Rationale: Untreated fluid overload can lead to complications such as pulmonary edema and congestive heart failure. Pulmonary edema occurs when excess fluid accumulates in the lungs, leading to difficulty breathing and potentially life-threatening respiratory distress. Congestive heart failure can result from the heart's inability to pump effectively due to the excess fluid volume, leading to symptoms such as fatigue, shortness of breath, and fluid retention. Choices B, C, and D are incorrect because hypertension, liver failure, pulmonary embolism, and dehydration are not the primary complications directly associated with untreated fluid overload.

3. A nurse is reinforcing discharge teaching about car seat safety with the guardian of a newborn. Which of the following statements by the guardian indicates an understanding of the teaching?

• A. I will position the car seat in the front seat
• B. I will secure the car seat in the car by using the seatbelt
• C. I will use a rear-facing car seat
• D. I will install the car seat facing forward

Correct answer: C

Rationale: The correct answer is C. Using a rear-facing car seat is the safest position for a newborn. Newborns should always be placed in a rear-facing car seat in the back seat of the vehicle to provide optimal safety in case of a crash. Choice A is incorrect because placing the car seat in the front seat is not safe due to the presence of airbags. Choice B is incorrect as securing the car seat using the seatbelt is not specific to the correct positioning of the car seat. Choice D is incorrect because installing the car seat facing forward is not recommended for newborns as it does not provide the same level of protection as a rear-facing position.

4. A healthcare professional is collecting data from a client who has hypokalemia. Which of the following findings should the healthcare professional expect?

• A. Muscle stiffness
• B. Bradycardia
• C. Hyperreflexia
• D. Muscle weakness

Correct answer: D

Rationale: The correct answer is 'Muscle weakness.' Hypokalemia is characterized by low potassium levels, which can lead to muscle weakness due to impaired muscle function. Choices A, B, and C are incorrect findings associated with other medical conditions and not typically expected in hypokalemia. Muscle stiffness is more commonly associated with conditions like tetany or muscle cramps, bradycardia is more commonly associated with issues like heart block or hypothyroidism, and hyperreflexia is more commonly seen in conditions like hyperthyroidism or spinal cord injuries.

5. A client has undergone a myelogram, and a nurse is providing post-procedure care. Which action should be included in the nursing care plan?

• A. Encourage ambulation after the procedure
• B. Maintain the prone position for 12 hours
• C. Evaluate the client's distal pulses on the affected side
• D. Encourage oral fluid intake

Correct answer: C

Rationale: The correct action to include in the nursing care plan for a client post-myelogram is to evaluate the client's distal pulses on the affected side. This is crucial to assess circulation and detect any potential complications such as impaired blood flow or vascular issues. Encouraging ambulation after the procedure (Choice A) is not typically recommended immediately post-myelogram, as the client may need to rest. Maintaining the prone position for 12 hours (Choice B) is an outdated practice and is no longer part of standard care post-myelogram. Encouraging oral fluid intake (Choice D) is generally beneficial for hydration but is not a specific priority related to post-myelogram care.

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