Nursing Elites

1. Which of the following might the nurse assess in a patient diagnosed with hypermagnesemia?

• A. Diminished deep tendon reflexes
• B. Tachycardia
• C. Cool clammy skin
• D. Increased serum magnesium

Correct answer: A

Rationale: The correct answer is A: Diminished deep tendon reflexes. In a patient with hypermagnesemia, the nurse would assess for diminished deep tendon reflexes. Hypermagnesemia can lead to neuromuscular depression, causing a decrease in deep tendon reflexes. Tachycardia (choice B) is more commonly associated with hypomagnesemia. Cool clammy skin (choice C) is not typically a direct symptom of hypermagnesemia. While hypermagnesemia does involve increased serum magnesium levels (choice D), assessing serum levels is a laboratory test and not a clinical assessment like checking deep tendon reflexes.

2. A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and feeling warm. For which complication of this therapy should the nurse assess this client?

• A. Allergic reaction
• B. Bowel obstruction
• C. Catheter lumen occlusion
• D. Infection

Correct answer: D

Rationale:

3. What percentage of body water can be as high as in a newborn?

• A. 80%.
• B. 70%.
• C. 60%.
• D. 90%.

Correct answer: A

Rationale: The correct answer is A: 80%. Newborns can have a body water content as high as 80% due to their higher total body water compared to adults. Choice B (70%) is incorrect because newborns typically have a higher body water percentage. Choice C (60%) is also incorrect as it underestimates the body water content in newborns. Choice D (90%) is incorrect as it overestimates the body water percentage in newborns.

4. A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital?

• A. Ask family members to speak quietly to keep the client calm.
• B. Assess urine color, amount, and specific gravity each day.
• C. Encourage the client to drink at least 1 liter of fluids each shift.
• D. Dangle the client on the bedside before ambulating.

Correct answer: D

Rationale: The correct answer is to 'dangle the client on the bedside before ambulating.' This intervention helps prevent orthostatic hypotension, a drop in blood pressure when changing positions, which is crucial in preventing falls and related injuries in older adult clients. Asking family members to speak quietly (Choice A) may help keep the client calm but does not directly address the risk of injury. Assessing urine parameters (Choice B) is important for monitoring hydration status but does not specifically prevent injury. Encouraging increased fluid intake (Choice C) is essential for managing dehydration but does not directly address the risk of injury during ambulation.

5. A nurse sees a variety of patients in the community health clinic. Which of the following patients would be at the greatest risk of dehydration?

• A. An 18-year-old basketball player with a stress fracture of the right foot
• B. An infant with diarrhea
• C. A 45-year-old with stomach flu
• D. An elderly patient living alone

Correct answer: B

Rationale: The correct answer is B. Infants are particularly vulnerable to dehydration due to diarrhea because they have a higher fluid turnover and less reserve. Option A, the 18-year-old basketball player with a stress fracture, is less likely to be at the greatest risk of dehydration compared to an infant with diarrhea. Option C, the 45-year-old with stomach flu, may experience dehydration but is not at the same level of risk as an infant with diarrhea. Option D, the elderly patient living alone, could be at risk of dehydration, but infants with diarrhea are at the greatest risk due to their unique physiological characteristics.

Similar Questions