Nursing Elites

1. What are the signs and symptoms of fluid overload, and how should a nurse manage this condition?

• A. Edema, weight gain, shortness of breath
• B. Fever, cough, chest pain
• C. Increased heart rate, low blood pressure
• D. Increased blood pressure, jugular venous distention

Correct answer: A

Rationale: Fluid overload manifests as edema, weight gain, and shortness of breath. These symptoms occur due to an excess of fluid in the body. Managing fluid overload involves interventions such as monitoring fluid intake and output, adjusting diuretic therapy, restricting fluid intake, and collaborating with healthcare providers to address the underlying cause. Choices B, C, and D are incorrect because they do not represent typical signs of fluid overload. Fever, cough, chest pain, increased heart rate, low blood pressure, increased blood pressure, and jugular venous distention are not primary indicators of fluid overload.

2. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer oxytocin
• B. Perform fundal massage
• C. Administer IV fluids
• D. Call the provider

Correct answer: B

Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.

3. What is the priority when managing a client with a chest tube postoperatively?

• A. Clamp the chest tube for 30 minutes every 4 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The priority when managing a client with a chest tube postoperatively is to check for air leaks and ensure the proper functioning of the chest tube. This is crucial to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube intermittently can lead to a buildup of pressure in the pleural space and should not be done without a specific medical indication. Encouraging deep breathing and coughing helps with lung expansion but is not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing may increase the risk of dislodging the chest tube or causing complications.

4. A healthcare professional is preparing to administer a blood transfusion. What is the first step?

• A. Administer the blood through an IV push
• B. Verify that the client's blood type matches the blood product
• C. Ensure the client has eaten before the transfusion
• D. Administer a diuretic before starting the transfusion

Correct answer: B

Rationale: The correct first step before administering a blood transfusion is to verify that the client's blood type matches the blood product. This step is crucial to prevent transfusion reactions due to incompatibility. Choice A is incorrect because blood should not be administered through an IV push for a blood transfusion. Choice C is incorrect because it is not necessary for the client to eat before a blood transfusion. Choice D is incorrect because administering a diuretic is not a standard practice before starting a blood transfusion.

5. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following findings should the nurse report to the provider?

• A. Blood glucose level of 120 mg/dL
• B. White blood cell count of 8,000/mm³
• C. Temperature of 37.2°C (99°F)
• D. Daily weight increase of 0.45 kg (1 lb)

Correct answer: D

Rationale: The correct answer is D. A sudden weight increase may indicate fluid retention, a complication of TPN therapy that should be reported. Options A, B, and C are within normal ranges and do not directly relate to TPN therapy complications. A blood glucose level of 120 mg/dL is normal, a white blood cell count of 8,000/mm³ is within the normal range, and a temperature of 37.2°C (99°F) is also normal.

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