Nursing Elites

1. What is the best way to assess for fluid overload in a patient with heart failure?

• A. Check daily weight
• B. Check blood pressure
• C. Monitor heart sounds
• D. Assess for jugular vein distention

Correct answer: A

Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.

2. A nurse is preparing to administer dopamine hydrochloride at 4 mcg/kg/min for a client weighing 80 kg. How many mL/hr should the nurse set the IV infusion to deliver?

• A. 6 mL/hr
• B. 8 mL/hr
• C. 12 mL/hr
• D. 16 mL/hr

Correct answer: A

Rationale: To calculate the correct rate, you first need to convert the weight to micrograms: 4 mcg/kg/min * 80 kg = 320 mcg/min. Then, convert micrograms to milligrams: 320 mcg/min / 1000 = 0.32 mg/min. Next, calculate how many milligrams per hour: 0.32 mg/min * 60 min/hr = 19.2 mg/hr. Finally, determine the mL/hr rate by using the concentration provided: 19.2 mg/hr / 800 mg in 250 mL = 6 mL/hr. Therefore, the correct answer is 6 mL/hr. Choice B, 8 mL/hr, is incorrect as it does not reflect the accurate calculation based on the weight and drug concentration. Choices C and D, 12 mL/hr and 16 mL/hr, are also incorrect as they do not align with the correct calculation of the infusion rate for dopamine hydrochloride based on the client's weight and the medication concentration.

3. A nurse is preparing to perform postmortem care for a client. Which of the following actions should the nurse take?

• A. Place the client's dentures in a labeled container
• B. Remove the client's IV lines
• C. Place the client's body in a semi-fowler's position
• D. Lower the client's head of the bed

Correct answer: B

Rationale: The correct action for the nurse to take when preparing to perform postmortem care is to remove the client's IV lines. This step is essential to help maintain the dignity and appearance of the body. Placing the client's dentures in a labeled container (Choice A) is not a priority during postmortem care as the focus is on the body's preparation. While positioning the body in a semi-fowler's position (Choice C) or lowering the client's head of the bed (Choice D) are common practices for living clients to prevent aspiration, they are not necessary after death. Therefore, the immediate action of removing IV lines is most appropriate in this situation.

4. A nurse is reviewing the medical record of a client who has hypothyroidism. Which of the following findings should the nurse expect?

• A. Weight gain of 1.4 kg (3 lb) in the past 2 weeks.
• B. Exophthalmos.
• C. Tachycardia.
• D. Heat intolerance.

Correct answer: A

Rationale: The correct answer is A. Weight gain can indicate myxedema, which is a symptom commonly seen in hypothyroidism. Exophthalmos (choice B) is actually a characteristic finding of hyperthyroidism, not hypothyroidism. Tachycardia (choice C) and heat intolerance (choice D) are also more indicative of hyperthyroidism rather than hypothyroidism.

5. A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime.
• B. Take your pulse before taking this medication.
• C. Avoid eating foods high in potassium.
• D. Take this medication with an antacid.

Correct answer: B

Rationale: The correct instruction for the nurse to include is to advise the client to take their pulse before taking digoxin. This is important to monitor for bradycardia, a potential side effect of the medication. Option A is incorrect because digoxin is usually taken in the morning. Option C is unrelated to digoxin therapy, as high potassium foods are usually restricted in clients taking potassium-sparing diuretics. Option D is incorrect because digoxin should not be taken with antacids as they can affect its absorption.

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