Nursing Elites

1. What should be done to ensure safety during the transfer of a patient with limited mobility?

• A. Have the patient use a gait belt for support.
• B. Encourage the patient to hold onto a walker.
• C. Lock the wheels on the bed and wheelchair.
• D. Ask the patient to transfer independently.

Correct answer: C

Rationale: The correct answer is to lock the wheels on the bed and wheelchair. This action helps prevent accidents by stabilizing the equipment during the transfer process. Having the patient use a gait belt for support (choice A) can be helpful but is not directly related to equipment safety. Encouraging the patient to hold onto a walker (choice B) is beneficial for ambulation but does not address the safety of equipment. Asking the patient to transfer independently (choice D) can pose risks, especially for a patient with limited mobility, and may not ensure safety during the transfer.

2. How is the effectiveness of a diuretic in a patient with heart failure evaluated?

• A. Checking daily weights and lung sounds for improvement
• B. Assessing the patient's blood pressure and urine output
• C. Monitoring for weight loss and reduction in edema
• D. Measuring the patient's heart rate and lung sounds

Correct answer: A

Rationale: The correct way to evaluate the effectiveness of a diuretic in a patient with heart failure is by checking daily weights and lung sounds for improvement. Daily weights help to assess fluid retention changes, while improvement in lung sounds indicates reduced pulmonary congestion. Assessing blood pressure and urine output (Choice B) is important but does not directly evaluate the effectiveness of the diuretic. Monitoring for weight loss and reduction in edema (Choice C) are valid indicators of diuretic effectiveness, but direct observation of daily weights and lung sounds is more specific. Measuring heart rate and lung sounds (Choice D) is relevant but does not directly assess the impact of the diuretic on fluid balance and pulmonary status.

3. A healthcare provider is caring for a client who has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?

• A. Bladder scan shows 525 mL
• B. Absent urinary output for 1 hour
• C. Cloudy urine
• D. Bloody urine

Correct answer: A

Rationale: The correct answer is A. A large bladder scan result (525 mL) suggests catheter blockage and may require irrigation to resolve. Choice B (absent urinary output for 1 hour) could indicate a different issue such as urinary retention but does not specifically indicate the need for catheter irrigation. Choices C (cloudy urine) and D (bloody urine) may suggest infection or other urinary issues, but they do not directly indicate the need for catheter irrigation.

4. A patient with heart failure needs education on fluid restrictions. What is the most important information to provide?

• A. Monitor the patient's weight daily.
• B. Provide the patient with a fluid restriction plan.
• C. Instruct the patient to avoid salty foods.
• D. Encourage the patient to increase fluid intake.

Correct answer: B

Rationale: The most important information to provide to a patient with heart failure regarding fluid restrictions is to provide them with a fluid restriction plan. This plan helps the patient manage their fluid intake effectively, which is crucial in preventing complications associated with heart failure. Monitoring weight daily can be a part of the plan but is not the most important. Instructing the patient to avoid salty foods is beneficial but not as crucial as having a structured fluid restriction plan. Encouraging the patient to increase fluid intake would be counterproductive and potentially harmful in a patient with heart failure.

5. What are the clinical manifestations of hypovolemic shock, and how should a nurse respond?

• A. Hypertension, bradycardia, and oliguria
• B. Bradycardia, hypertension, and peripheral edema
• C. Tachypnea, cool skin, and confusion
• D. Tachycardia, hypotension, and decreased urine output

Correct answer: D

Rationale: The correct answer is D: Tachycardia, hypotension, and decreased urine output are classic clinical manifestations of hypovolemic shock. In hypovolemic shock, the body tries to compensate for low blood volume by increasing the heart rate (tachycardia) to maintain cardiac output, leading to hypotension and decreased urine output. Prompt fluid replacement is necessary to restore intravascular volume. Choices A, B, and C are incorrect because they do not represent the typical manifestations of hypovolemic shock.

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