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 preparing to administer a dose of amoxicillin to a client who has an allergy to penicillin. Which of the following actions should the nurse take?

• A. Administer the medication as prescribed.
• B. Verify the client's allergy status before administering the medication.
• C. Ask the provider to prescribe a different antibiotic.
• D. Check the client's skin for any rashes before administering the medication.

Correct answer: C

Rationale: In this scenario, the nurse should ask the provider to prescribe a different antibiotic instead of administering amoxicillin to a client with a known penicillin allergy. Choice A is incorrect because administering amoxicillin to a client with a penicillin allergy can lead to an allergic reaction. Choice B is not the best option as simply verifying the client's allergy status does not address the potential harm of giving amoxicillin. Choice D is irrelevant as checking the client's skin for rashes does not address the issue of administering a potentially harmful medication. Therefore, the most appropriate action is to request a different antibiotic from the provider to ensure the safety of the client.

3. Which lab value is critical for a patient on heparin therapy?

• A. Monitor aPTT
• B. Monitor INR
• C. Monitor platelet count
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor aPTT. Activated Partial Thromboplastin Time (aPTT) is crucial for patients on heparin therapy as it helps determine the clotting ability of the blood. By monitoring aPTT, healthcare providers can adjust the dosage of heparin to maintain therapeutic levels and prevent bleeding complications. Monitoring INR is more commonly associated with warfarin therapy, not heparin. Monitoring platelet count is important for assessing the risk of bleeding or clotting disorders but is not specific to heparin therapy. Monitoring sodium levels is not directly related to assessing the effectiveness or safety of heparin therapy.

4. A client is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Temperature of 37.1°C (98.8°F)
• C. Serosanguineous wound drainage
• D. Urine output of 25 mL/hr

Correct answer: D

Rationale: A urine output of 25 mL/hr is a sign of oliguria, which may indicate dehydration or kidney impairment and should be reported. A heart rate of 90/min is within the normal range (60-100/min) for adults at rest and may be expected postoperatively. A temperature of 37.1°C (98.8°F) is within the normal range (36.1-37.2°C or 97-99°F) and does not indicate an immediate concern. Serosanguineous wound drainage is a common finding postoperatively and indicates a normal healing process.

5. A charge nurse is teaching new staff members about factors that increase a client's risk of becoming violent. Which of the following risk factors should the nurse include as the best predictor of future violence?

• A. Experiencing delusions.
• B. Male gender.
• C. Previous violent behavior.
• D. A history of being in prison.

Correct answer: C

Rationale: The correct answer is C: Previous violent behavior. This is the best predictor of future violence as individuals who have a history of violent behavior are more likely to engage in violent acts in the future. While experiencing delusions and being male may contribute to an increased risk of violence in certain situations, they are not as strong predictors as a history of violence. Similarly, having a history of being in prison may indicate a higher likelihood of violence, but it is not as directly linked to future violent behavior as previous violent actions.

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