Nursing Elites

1. What is the best method to monitor fluid balance in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Monitor blood pressure
• D. Monitor edema

Correct answer: A

Rationale: The best method to monitor fluid balance in a patient receiving diuretics is to monitor daily weight. Daily weighing is a precise way to assess changes in fluid status as it reflects variations in total body water. Monitoring intake and output (choice B) is also important but may not provide as accurate a measurement as daily weight. Monitoring blood pressure (choice C) is essential but does not directly measure fluid balance. Monitoring edema (choice D) is helpful to assess fluid status visually but may not be as sensitive as daily weight measurements in detecting subtle changes in fluid balance.

2. A healthcare provider is providing discharge instructions to a client with type 2 diabetes mellitus. Which resource should the healthcare provider provide?

• A. Personal blogs about managing the adverse effects of diabetes medications.
• B. Food label recommendations from the Institute of Medicine.
• C. Diabetes medication information from the Physicians' Desk Reference.
• D. Food exchange lists for meal planning from the American Diabetes Association.

Correct answer: D

Rationale: Food exchange lists from the American Diabetes Association are a valuable resource for structured meal planning in individuals with diabetes. These lists categorize foods based on macronutrient content and help individuals plan balanced meals to manage blood sugar levels effectively. Personal blogs may not always provide accurate and evidence-based information. Food label recommendations from the Institute of Medicine are important but may not be as specific to meal planning for diabetes. Diabetes medication information is crucial but not the primary focus when providing dietary instructions.

3. A client receiving warfarin is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will avoid eating leafy green vegetables while taking this medication.
• B. I will need to have my INR checked regularly while taking this medication.
• C. I will take this medication at the same time each day.
• D. I will avoid taking aspirin while taking this medication.

Correct answer: D

Rationale: The correct answer is D because clients taking warfarin should avoid aspirin to reduce the risk of bleeding, as both medications can thin the blood. Choice A is incorrect because it is essential to eat a consistent amount of leafy green vegetables to maintain a steady intake of Vitamin K, which can impact warfarin's effectiveness. Choice B is incorrect although important because INR checks are necessary but do not specifically show an understanding of the teaching. Choice C is incorrect because while taking warfarin at the same time each day is beneficial for consistency, it does not directly address the interaction with aspirin.

4. A healthcare provider is preparing to administer an intramuscular injection to a client. Which of the following actions should the provider take?

• A. Insert the needle at a 90-degree angle
• B. Insert the needle at a 45-degree angle
• C. Inject the medication slowly after aspiration
• D. Massage the site after injection

Correct answer: A

Rationale: Correct answer: When administering an intramuscular injection, the needle should be inserted at a 90-degree angle to ensure proper delivery of the medication into the muscle tissue. Option B is incorrect because a 45-degree angle is typically used for subcutaneous injections, not intramuscular. Option C is incorrect as aspiration is not recommended for intramuscular injections. Option D is incorrect as massaging the site after an intramuscular injection can cause tissue damage or interfere with the absorption of the medication.

5. A client in active labor has ruptured membranes. What action should the nurse take?

• A. Apply a fetal heart rate monitor.
• B. Initiate fundal massage.
• C. Administer oxytocin IV.
• D. Insert an indwelling urinary catheter.

Correct answer: A

Rationale: When a client in active labor has ruptured membranes, the priority action for the nurse is to apply a fetal heart rate monitor. This is crucial for continuous monitoring of the baby's heart rate and ensuring fetal well-being. Initiating fundal massage may be indicated for uterine atony after delivery, not for ruptured membranes during labor. Administering oxytocin IV could be appropriate in some cases to augment labor, but it is not the immediate priority after ruptured membranes. Inserting an indwelling urinary catheter is not necessary solely based on ruptured membranes; it may be indicated for specific situations like epidural anesthesia where the client cannot void.

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