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. What are the complications of untreated pneumonia?

• A. Sepsis and respiratory failure
• B. Heart failure and kidney failure
• C. Pulmonary embolism and electrolyte imbalance
• D. Liver failure and electrolyte imbalance

Correct answer: A

Rationale: The correct answer is A: Sepsis and respiratory failure. Untreated pneumonia can lead to severe complications such as sepsis, which is a life-threatening response to infection, and respiratory failure, where the lungs can no longer provide enough oxygen to the body. Heart failure and kidney failure (choice B) are not direct complications of untreated pneumonia. Pulmonary embolism and electrolyte imbalance (choice C) are also not commonly associated with untreated pneumonia. Liver failure and electrolyte imbalance (choice D) are not typical complications of pneumonia.

3. A nurse is caring for a client who has heart failure and is receiving digoxin. Which of the following findings should the nurse identify as a sign of digoxin toxicity?

• A. Bradycardia
• B. Tachycardia
• C. Hypotension
• D. Increased appetite

Correct answer: A

Rationale: Corrected Rationale: Bradycardia is a common sign of digoxin toxicity. Digoxin, a medication used to treat heart failure, works by slowing down the heart rate and increasing the force of heart contractions. Excessive levels of digoxin can lead to toxicity, causing bradycardia (slow heart rate), among other symptoms. Tachycardia (fast heart rate) and hypotension (low blood pressure) are not typically associated with digoxin toxicity. Increased appetite is not a recognized sign of digoxin toxicity; instead, gastrointestinal symptoms like nausea, vomiting, and anorexia are more common.

4. A nurse is collecting data from a client who has Tourette syndrome. The client reports taking haloperidol 0.5 mL orally three times a day at home. Which of the following components of the prescription should the nurse question?

• A. Frequency
• B. Dosage
• C. Timing of doses
• D. Route

Correct answer: B

Rationale: The nurse should question the dosage of haloperidol as it is typically administered in milligrams (mg) and not milliliters (mL). The dosage should be expressed in a standardized unit for accuracy and to prevent medication errors. Frequency, timing of doses, and route are also important components of a prescription, but in this case, the nurse should focus on the unusual dosage form.

5. A client with dementia is at risk of falls. Which intervention should the nurse implement to ensure safety?

• A. Use restraints to prevent the client from leaving the bed
• B. Use a bed exit alarm to notify staff when the client tries to leave the bed
• C. Encourage frequent ambulation with assistance
• D. Raise all four side rails to prevent falls

Correct answer: B

Rationale: The correct intervention for a client with dementia at risk of falls is to use a bed exit alarm to notify staff when the client tries to leave the bed. This intervention helps prevent falls while still allowing some freedom of movement. Choice A is incorrect because using restraints can lead to complications and is considered a form of restraint which should be avoided. Choice C is not suitable for a client at high risk of falls due to dementia as it may increase the risk of falls. Choice D is not recommended as raising all four side rails can be considered a form of physical restraint and may not be the best approach to prevent falls in a client with dementia.

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