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Which of the following is the best indicator of fluid balance in a patient with heart failure?
- A. Daily weight measurements.
- B. Monitoring intake and output.
- C. Assessing skin turgor.
- D. Checking for peripheral edema.
Correct Answer: A
Rationale: Daily weight measurements are the best indicator of fluid balance in a patient with heart failure. Changes in weight reflect fluid retention or loss more accurately than other methods. Monitoring intake and output (choice B) is essential but may not provide a comprehensive picture of fluid status. Skin turgor (choice C) and checking for peripheral edema (choice D) are more indicative of dehydration and fluid overload, respectively, rather than overall fluid balance.
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Which of the following is most important for assessing when evaluating the effects of peritoneal dialysis?
- A. Serum potassium levels
- B. Blood pressure
- C. Daily weight
- D. Serum sodium levels
Correct Answer: C
Rationale: Daily weight is the most crucial parameter to assess when evaluating the effects of peritoneal dialysis because it directly reflects fluid balance. Peritoneal dialysis involves the removal of excess fluid and waste products from the body. Monitoring daily weight enables the healthcare provider to track changes in fluid status, ensuring that the dialysis treatment is effective. While serum potassium levels, blood pressure, and serum sodium levels are important parameters to monitor in patients undergoing dialysis, they are not as directly indicative of the immediate effects of peritoneal dialysis on fluid balance as daily weight.
The healthcare provider is assessing an older Caucasian male who has a history of peripheral vascular disease. The healthcare provider observes that the man's left great toe is black. The discoloration is probably a result of:
- A. Atrophy.
- B. Contraction.
- C. Gangrene.
- D. Rubor.
Correct Answer: C
Rationale: Gangrene refers to dead, blackened tissue, often a result of chronic ischemia in clients with peripheral vascular disease. Atrophy (Choice A) is the wasting away or decrease in size of tissue or organ. Contraction (Choice B) refers to the shortening or tightening of a muscle or other body part. Rubor (Choice D) is a red discoloration of the skin, often associated with inflammation or poor circulation, but not typically presenting as blackening like gangrene.
A client with chronic renal failure is receiving epoetin alfa (Epogen) to treat anemia. The nurse should assess the client for which of the following side effects?
- A. Hypertension.
- B. Hypotension.
- C. Infection.
- D. Edema.
Correct Answer: A
Rationale: The correct answer is A: Hypertension. Epoetin alfa (Epogen) is a medication used to treat anemia in clients with chronic renal failure. One common side effect of this medication is hypertension. Epoetin alfa stimulates red blood cell production, which can lead to an increase in blood pressure. Therefore, the nurse should closely monitor the client for signs and symptoms of hypertension while on this medication. Choices B, C, and D are incorrect. Hypotension is not typically associated with epoetin alfa administration. Infection is not a direct side effect of epoetin alfa. Edema is also not a common side effect of this medication.
An adult client who received partial thickness burns on 40% of the body in a house fire is admitted to the inpatient burn unit. Which fluid should the nurse prepare to administer during the client's burn recovery?
- A. 5% dextrose in water
- B. 5% dextrose in 0.25 normal saline
- C. Total parenteral nutrition
- D. Lactated Ringer's
Correct Answer: D
Rationale: During the burn recovery phase, the nurse should prepare to administer Lactated Ringer's solution. Lactated Ringer's is the preferred fluid choice for burn patients as it helps replace lost fluids and electrolytes, maintain perfusion, and support organ function. Option A, 5% dextrose in water, is not the appropriate choice for fluid resuscitation in burn patients. Option B, 5% dextrose in 0.25 normal saline, does not provide the necessary electrolytes needed for burn recovery. Option C, Total parenteral nutrition, may be considered later in the treatment but is not the initial fluid of choice for burn recovery.
Which of the following is a characteristic of chronic obstructive pulmonary disease (COPD)?
- A. Increased lung compliance.
- B. Decreased lung elasticity.
- C. Increased respiratory rate.
- D. Increased lung expansion.
Correct Answer: B
Rationale: The correct answer is B: Decreased lung elasticity. Chronic obstructive pulmonary disease (COPD) is characterized by a loss of lung elasticity, which leads to difficulty in exhaling air. This decreased elasticity results in air becoming trapped in the lungs, making it challenging for the individual to breathe effectively. Choice A is incorrect as COPD is associated with decreased lung compliance, not increased compliance. Choice C is incorrect as individuals with COPD often have a decreased respiratory rate due to impaired lung function. Choice D is incorrect as COPD causes limited lung expansion due to factors like air trapping and hyperinflation.