Nursing Elites

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

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

Correct answer: A

Rationale: Corrected Rationale: Daily weight monitoring is the most accurate way to assess fluid balance in patients receiving diuretics. Monitoring daily weight allows healthcare providers to track changes in fluid status more precisely. While monitoring intake and output (choice B) is essential, it may not provide a comprehensive picture of overall fluid balance. Monitoring blood pressure (choice C) is important but may not directly reflect fluid balance. Checking for edema (choice D) is useful but may not be as sensitive as daily weight monitoring in assessing fluid balance.

2. A nurse is assessing a client who has schizophrenia and is taking chlorpromazine. Which of the following findings should the nurse identify as an adverse effect of the medication?

• A. Weight gain
• B. Dry mouth
• C. Sedation
• D. Diarrhea

Correct answer: C

Rationale: The correct answer is C: Sedation. Chlorpromazine, an antipsychotic medication, commonly causes sedation as an adverse effect. Weight gain (choice A) is a potential side effect of some antipsychotic medications, but it is not specifically associated with chlorpromazine. Dry mouth (choice B) is a common anticholinergic side effect of many medications but is not a prominent adverse effect of chlorpromazine. Diarrhea (choice D) is not a typical adverse effect of chlorpromazine.

3. A nurse is providing discharge teaching for a group of clients. The nurse should recommend a referral to a dietitian.

• A. A client who has a prescription for warfarin and states, 'I will need to limit how much spinach I eat.'
• B. A client who has gout and states, 'I can continue to eat anchovies on my pizza.'
• C. A client who has a prescription for spironolactone and states, 'I will reduce my intake of foods that contain potassium.'
• D. A client who has osteoporosis and states, 'I'll plan to take my calcium carbonate with a full glass of water.'

Correct answer: C

Rationale: The correct answer is C. Spironolactone is a potassium-sparing diuretic, which means it helps the body retain potassium and excrete sodium and water. Therefore, clients on spironolactone should reduce their intake of foods high in potassium to prevent hyperkalemia. Choices A, B, and D are incorrect because limiting spinach intake due to warfarin, eating anchovies with gout, and taking calcium carbonate with water for osteoporosis do not directly relate to the medication's side effects or dietary restrictions associated with spironolactone.

4. A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?

• A. Tell the client that their delusions are not real
• B. Encourage the client to explore the meaning behind their delusions
• C. Focus on the client's feelings rather than the delusions
• D. Challenge the client's delusions directly

Correct answer: C

Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.

5. What is the priority nursing intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Reposition the patient
• C. Administer bronchodilators
• D. Administer IV fluids

Correct answer: A

Rationale: The correct answer is to administer oxygen. In a patient experiencing respiratory distress, ensuring adequate oxygenation is the priority. Administering oxygen helps improve oxygen levels, which is crucial for the patient's well-being. Repositioning the patient, administering bronchodilators, or giving IV fluids are important interventions in certain situations, but when a patient is in respiratory distress, providing oxygen takes precedence over other actions.

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