Nursing Elites

1. While taking the history of an older adult client, which assessment finding alerts the nurse that the client needs further assessment for fluid or electrolyte imbalance?

• A. "I am often cold and need to wear a sweater."?
• B. "I seem to urinate more when I drink coffee."?
• C. "In the summer, I feel thirsty more often."?
• D. "My rings seem to be tighter this week."?

Correct answer: D

Rationale: The correct answer is 'My rings seem to be tighter this week.' This assessment finding indicates possible fluid retention, which can be a sign of fluid or electrolyte imbalance in an older adult. Choices A, B, and C do not specifically point towards fluid or electrolyte imbalance. Feeling cold, increased urination with coffee consumption, and feeling thirsty in the summer are not direct indicators of fluid or electrolyte imbalance in this context.

2. The nurse assesses distended neck veins in a client sitting in a chair to eat. What intervention is the nurse's priority?

• A. Document the observation in the chart.
• B. Measure urine specific gravity and volume.
• C. Assess the pulse and blood pressure.
• D. Assess the client's deep tendon reflexes.

Correct answer: C

Rationale: The correct answer is to assess the pulse and blood pressure. Distended neck veins can indicate fluid volume overload or heart failure, which can lead to hemodynamic instability. Assessing the pulse and blood pressure will provide immediate information on the client's cardiovascular status. Documenting the observation in the chart (choice A) is important but not the priority when immediate assessment is needed. Measuring urine specific gravity and volume (choice B) is important for assessing renal function but is not the priority in this situation. Assessing the client's deep tendon reflexes (choice D) is not relevant to addressing distended neck veins in a client sitting to eat.

3. The healthcare provider is assessing a client before surgery. Which assessments contraindicate the client from having surgery as scheduled? (Select one that does not apply.)

• A. Potassium level of 2.8 mEq/L
• B. International normalized ratio (INR) of 4
• C. Prothrombin time (PT) of 30 seconds
• D. Positive pregnancy test

Correct answer: C

Rationale: The correct answer is C: Prothrombin time (PT) of 30 seconds. A low potassium level (choice A) and an elevated INR (choice B) indicate potential bleeding risks during surgery. A positive pregnancy test (choice D) in a female client can lead to complications during surgery. However, a Prothrombin time of 30 seconds is within the normal range and does not contraindicate the client from having surgery as scheduled.

4. A client is receiving an IV infusion of an antibiotic. The client calls the nurse feeling uneasy due to congestion. Which action by the nurse is most appropriate?

• A. Elevate the head of the client's bed to 45 degrees
• B. Have another nurse call the Rapid Response Team
• C. Prepare to administer diphenhydramine (Benadryl)
• D. Slow the rate of the IV infusion

Correct answer: B

Rationale: In this situation, the client's symptoms of congestion and feeling uneasy may indicate an anaphylactic reaction, which can be life-threatening. The most appropriate action is to call the Rapid Response Team to provide immediate assistance and interventions. Elevating the head of the bed, administering diphenhydramine, or slowing the IV infusion rate are not the priority actions in the case of a potential severe allergic reaction. These interventions may delay necessary emergency care and potentially worsen the client's condition.

5. How does the nurse interpret the client's actions of combing her hair only on the right side of her head and washing only the right side of her face after a stroke?

• A. Poor left-sided motor control
• B. Paralysis or contractures on the right side
• C. Limited visual perception of the left fields
• D. Unawareness of the existence of her left side

Correct answer: D

Rationale: The client's selective grooming and washing habits indicate a condition known as 'unawareness of the existence of her left side,' also called hemispatial neglect. This condition is characterized by a lack of awareness or attention to one side of the body or space, typically the left side in stroke patients. Choices A, B, and C are incorrect because the client's actions are not due to poor motor control, paralysis, contractures, or limited visual perception. Instead, they are indicative of a specific cognitive deficit related to neglecting one side of the body.

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