Nursing Elites

1. The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is

• A. Body weight
• B. Intake and output
• C. Daily weight
• D. Skin turgor

Correct answer: C

Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.

2. A client is receiving IV fluid therapy for dehydration. Which assessment finding indicates that the client's fluid status is improving?

• A. Urine output increases to 50 mL/hour
• B. Client reports feeling more thirsty
• C. Blood pressure decreases from 120/80 to 110/70
• D. Heart rate increases from 80 to 100 beats per minute

Correct answer: A

Rationale: An increase in urine output is a positive sign that the client's hydration status is improving. It indicates that the kidneys are functioning well and that fluid therapy is effective. Increased urine output helps to eliminate excess fluid and waste products from the body. Choices B, C, and D are incorrect. Feeling more thirsty (choice B) is a sign of dehydration, not improvement. A decrease in blood pressure (choice C) and an increase in heart rate (choice D) are not typically indicative of improving fluid status during IV fluid therapy for dehydration.

3. A male client with heart failure presents with shortness of breath, audible wheezing, and pink frothy sputum. What action should the nurse take?

• A. Consult with the charge nurse regarding morphine prescription.
• B. Administer the dose of morphine sulfate as prescribed.
• C. Withhold morphine until dyspnea resolves.
• D. Review the need for the prescription with the healthcare provider.

Correct answer: B

Rationale: The correct answer is B: Administer the dose of morphine sulfate as prescribed. In heart failure, morphine helps reduce anxiety, preload, and afterload on the heart, improving oxygenation. The client's symptoms indicate acute decompensated heart failure, and morphine should be administered promptly to relieve distress. Consulting the charge nurse (Choice A) or withholding morphine (Choice C) would delay necessary treatment. Reviewing the prescription with the healthcare provider (Choice D) is not needed in this acute situation.

4. A middle-aged woman talks to the nurse in the healthcare provider's office about uterine fibroids, also called leiomyomas or myomas. What statement by the woman indicates more education is needed?

• A. I am one out of every 4 women that get fibroids, and among women my age, between the 30s or 40s, fibroids occur more frequently.
• B. My fibroids are noncancerous tumors that grow slowly.
• C. The associated problems I have had are pelvic pressure and pain, urinary incontinence, frequent urination or urine retention, and constipation.
• D. Fibroids that cause no problems still need to be taken out.

Correct answer: D

Rationale: The correct answer is D because fibroids that do not cause symptoms do not necessarily need to be removed unless they pose other health risks. Choice A provides accurate information about the prevalence of fibroids among women of the woman's age group. Choice B correctly describes fibroids as noncancerous tumors. Choice C lists common symptoms associated with fibroids, which is relevant information. However, choice D is incorrect as fibroids that are asymptomatic or not causing problems usually do not require treatment, unless they lead to complications or health risks.

5. A client admitted to the ICU with Syndrome of Inappropriate Antidiuretic Hormone (SIADH) has developed osmotic demyelination. What is the first intervention the nurse should implement?

• A. Evaluate the client's swallowing ability.
• B. Reorient the client frequently.
• C. Patch one eye to minimize confusion.
• D. Perform range of motion exercises.

Correct answer: A

Rationale: The correct answer is to evaluate the client's swallowing ability. Osmotic demyelination can cause dysphagia, putting the client at risk for aspiration. Assessing swallowing function is crucial to prevent complications such as aspiration pneumonia. Reorienting the client frequently (Choice B) is more suitable for confusion related to conditions like delirium. Patching one eye (Choice C) is a technique used for diplopia or double vision, not specifically indicated for osmotic demyelination. Performing range of motion exercises (Choice D) may be beneficial for preventing complications of immobility but is not the priority intervention for osmotic demyelination.

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