Nursing Elites

1. Which of the following organs does not contribute to fluid output from the body?

• A. Lungs
• B. Skin
• C. Intestine
• D. Lungs, skin, and intestine

Correct answer: D

Rationale: The correct answer is D. All the listed organs (lungs, skin, and intestines) contribute to fluid loss from the body. Lungs contribute to fluid loss through respiration, skin through sweating, and intestines through excretion. Therefore, none of the organs listed in the options retain fluids within the body. Choices A, B, and C are incorrect because all of these organs play a role in fluid output from the body.

2. A nurse evaluates a clients arterial blood gas values (ABGs): pH 7.30, PaO2 86 mm Hg, PaCO2 55 mm Hg, and HCO3 22 mEq/L. Which intervention should the nurse implement first?

• A. Assess the airway.
• B. Administer prescribed bronchodilators.
• C. Provide oxygen.
• D. Administer prescribed mucolytics

Correct answer: A

Rationale:

3. A nurse is visiting an 84-year-old woman living at home and recovering from hip surgery. The woman seems confused and has poor skin turgor, and she states that 'she stops drinking water early in the day because it is too difficult to get up during the night to go to the bathroom.' The nurse explains to the woman that:

• A. She will need to have her medications adjusted and be readmitted to the hospital for a complete workup.
• B. Limiting fluids can create imbalances in the body that can result in confusion; maybe we need to adjust the timing of your fluids.
• C. It is normal to be a little confused following surgery and it is safe not to urinate at night.
• D. Confusion following surgery is common in the elderly due to loss of sleep.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid deficits can lead to confusion and cognitive impairment. Limiting fluids can disrupt the body's balance, leading to such symptoms. Adjusting the timing of fluids can help maintain hydration without causing nighttime interruptions. Choices A, C, and D are incorrect because they do not address the underlying issue of fluid imbalance causing confusion. Choice A suggests unnecessary hospital readmission and medication adjustments. Choice C incorrectly normalizes confusion post-surgery and suggests it is safe not to urinate at night, which can exacerbate the issue. Choice D inaccurately attributes confusion to sleep loss rather than fluid imbalance.

4. During a visit to an 84-year-old woman recovering from hip surgery, the nurse notices signs of confusion and poor skin turgor. The woman mentions she limits water intake to avoid nighttime bathroom trips. The nurse should explain to the woman that:

• A. She will need her medications adjusted and be readmitted for a complete workup.
• B. Limiting fluids can lead to body imbalances causing confusion; perhaps adjusting fluid intake timing is necessary.
• C. Post-surgical confusion is common, and it's safe not to urinate at night.
• D. Confusion after surgery is typical in the elderly due to sleep loss.

Correct answer: B

Rationale: The correct answer is B. In elderly patients, fluid and electrolyte imbalances can manifest with subtle signs like confusion. Limiting fluids can lead to such imbalances, affecting cognitive function. Adjusting the timing of fluid intake can help maintain hydration without causing nighttime disruptions. Choices A, C, and D are incorrect. Choice A suggests unnecessary hospital readmission and medication adjustments without addressing the root cause. Choice C wrongly normalizes the confusion and fails to address the potential issue of fluid restriction. Choice D incorrectly attributes confusion solely to sleep loss without considering the impact of fluid balance.

5. A patient is in the hospital with heart failure. The nurse notes during the evening assessment that the patient's neck veins are distended and the patient has dyspnea. What action should the nurse take?

• A. Place the patient in low Fowler's position and notify the physician.
• B. Increase the patient's IV fluid and auscultate the lungs.
• C. Place the patient in semi-Fowler's position and prepare to give the PRN diuretic as ordered.
• D. Discontinue the patient's IV.

Correct answer: C

Rationale: The symptoms of distended neck veins and dyspnea indicate fluid overload in a patient with heart failure. Placing the patient in semi-Fowler's position helps with respiratory effort and administering diuretics, as ordered, can assist in reducing fluid volume. Placing the patient in low Fowler's position (Choice A) may not be as effective in improving breathing. Increasing IV fluid (Choice B) is contraindicated in fluid overload conditions. Discontinuing the IV (Choice D) is not the immediate intervention needed to address the symptoms of fluid overload.

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