Nursing Elites

1. Which of the following lab results is most indicative of dehydration?

• A. Low sodium levels.
• B. Elevated creatinine levels.
• C. Low potassium levels.
• D. High blood glucose levels.

Correct answer: B

Rationale: Elevated creatinine levels are indicative of dehydration because when the body is dehydrated, the kidneys concentrate urine to preserve fluid, leading to higher levels of creatinine. Low sodium levels (Choice A) can be seen in conditions like hyponatremia but are not specific to dehydration. Low potassium levels (Choice C) are more commonly associated with conditions like hypokalemia. High blood glucose levels (Choice D) are typically seen in diabetes and are not specific indicators of dehydration.

2. A client has undergone insertion of a permanent pacemaker. When developing a discharge teaching plan, the nurse writes a goal of, 'The client will verbalize symptoms of pacemaker failure.' Which symptoms are most important to teach the client?

• A. Facial flushing.
• B. Fever.
• C. Pounding headache.
• D. Feelings of dizziness.

Correct answer: D

Rationale: The correct answer is 'D: Feelings of dizziness.' Feelings of dizziness may occur as a result of a decreased heart rate, leading to decreased cardiac output, which can be an indication of pacemaker failure. Teaching the client to recognize symptoms of decreased cardiac output, like dizziness, is crucial for early detection of pacemaker malfunction. Choices A, B, and C are less specific to pacemaker failure and are not commonly associated with this condition. Facial flushing, fever, and pounding headache are not typical signs of pacemaker failure and are not directly related to cardiac output, making them less relevant for teaching the client about pacemaker failure.

3. A client in the intensive care unit is started on continuous venovenous hemofiltration (CVVH). Which finding should prompt immediate action by the nurse?

• A. Blood pressure of 76/58 mm Hg
• B. Sodium level of 138 mEq/L
• C. Potassium level of 5.5 mEq/L
• D. Pulse rate of 90 beats/min

Correct answer: A

Rationale: The correct answer is A: Blood pressure of 76/58 mm Hg. In a client undergoing continuous venovenous hemofiltration (CVVH), hypotension can be a significant concern if replacement fluid does not adequately maintain blood pressure. The nurse should take immediate action to address hypotension to prevent further complications. The sodium level of 138 mEq/L is within normal range, and a potassium level of 5.5 mEq/L, while slightly elevated, may be expected in a patient with acute kidney injury. A pulse rate of 90 beats/min falls within the normal range and does not typically require immediate intervention in this context.

4. A client who is receiving chemotherapy asks the nurse, 'Why is so much of my hair falling out each day?' Which response by the nurse best explains the reason for alopecia?

• A. 'Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant.'
• B. 'Alopecia is a common side effect you will experience during long-term steroid therapy.'
• C. 'Your hair will grow back completely after your course of chemotherapy is completed.'
• D. 'The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss.'

Correct answer: A

Rationale: The correct answer is A: 'Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant.' Chemotherapy targets rapidly dividing cells, which include not only cancer cells but also healthy cells like those in hair follicles. This leads to alopecia (hair loss) as a common side effect. Choice B is incorrect as alopecia is primarily associated with chemotherapy and not long-term steroid therapy. Choice C is incorrect because while hair may grow back after chemotherapy, it may not always be to the same extent or thickness. Choice D is incorrect as chemotherapy-induced hair loss is often temporary and reversible, not permanent alterations in hair follicles.

5. A client with a chest tube attached to a closed drainage system has undergone a chest x-ray, which revealed that the affected lung is fully reexpanded. The nurse anticipates that the next assessment of the chest tube system will reveal:

• A. No fluctuation in the water seal chamber
• B. Continuous bubbling in the water seal chamber
• C. Increased drainage in the collection chamber
• D. Continuous gentle suction in the suction control chamber

Correct answer: A

Rationale: When the client's lung is fully reexpanded, the chest tube drainage system will no longer be actively draining, and there will be no fluctuation in the water seal chamber. Option B, continuous bubbling in the water seal chamber, indicates an air leak in the system, which is not expected when the lung is fully expanded. Option C, increased drainage in the collection chamber, would not be expected when the lung is reexpanded as there should be minimal to no drainage. Option D, continuous gentle suction in the suction control chamber, would not be appropriate when the lung is fully reexpanded and the chest tube is typically on a water seal system at this point to promote reexpansion and prevent air from entering the pleural space.

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