Nursing Elites

1. What intervention is most important to teach the client about identifying the onset of dehydration?

• A. Measuring abdominal girth
• B. Converting ounces to milliliters
• C. Obtaining and charting daily weight
• D. Selecting food items with high water content

Correct answer: C

Rationale: The correct answer is C: Obtaining and charting daily weight. Monitoring daily weight is crucial in identifying the onset of dehydration as weight loss can be an early sign. Measuring abdominal girth (choice A) is not the most reliable method for detecting dehydration. Converting ounces to milliliters (choice B) and selecting food items with high water content (choice D) may be important for overall hydration but are not the most critical interventions for identifying the onset of dehydration.

2. A client is hospitalized with a urinary tract infection (UTI). Which clinical manifestation alerts the nurse to the possibility of a complication from the UTI?

• A. Burning on urination
• B. Cloudy, dark urine
• C. Fever and chills
• D. Hematuria

Correct answer: C

Rationale: Fever and chills are systemic symptoms that may indicate a more severe infection or a complication of a urinary tract infection (UTI). While burning on urination and cloudy, dark urine are common symptoms of UTI, fever and chills suggest a more serious condition requiring immediate attention. Hematuria, which is blood in the urine, is also a concerning symptom but is more indicative of inflammation or infection rather than a complication.

3. A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?

• A. Elevate the head of the client's bed to 45 degrees
• B. Have another nurse call the Rapid Response Team
• C. Prepare to administer diphenhydramine (Benadryl)
• D. Slow the rate of the IV infusion

Correct answer: B

Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.

4. While taking the history of an older adult client, which assessment finding alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?

• A. "I am often cold and need to wear a sweater."?
• B. "I seem to urinate more when I drink coffee."?
• C. "In the summer, I feel thirsty more often."?
• D. "My rings seem to be tighter this week."?

Correct answer: D

Rationale: The correct answer is 'My rings seem to be tighter this week.' This assessment finding indicates possible fluid retention, which can be a sign of fluid or electrolyte imbalance in an older adult. Choices A, B, and C do not specifically point towards fluid or electrolyte imbalance. Feeling cold, increased urination with coffee consumption, and feeling thirsty in the summer are not direct indicators of fluid or electrolyte imbalance in this context.

5. When the client finds antiembolism stockings uncomfortably tight, what is the nurse's best action?

• A. Remove the stockings for an hour to relieve the pressure
• B. Pull the stockings down so that they are not constricting
• C. Measure the client's calf to ensure that they are the correct size
• D. Teach the client the purpose of wearing the stockings

Correct answer: D

Rationale: The correct action for the nurse to take when a client finds antiembolism stockings uncomfortably tight is to teach the client the purpose of wearing the stockings. This educates the client on the importance of the stockings in preventing blood clots and encourages compliance. Removing the stockings or pulling them down may compromise their effectiveness. Measuring the client's calf size is not necessary in this situation as the discomfort is due to tightness, not incorrect sizing.

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