Question

A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

Answer 1

Correct Answers:

Decrease in heart rate

Rationale :

💧 A decrease in heart rate indicates improved circulating blood volume after fluid replacement.

💧 In fluid volume deficit, tachycardia occurs as a compensatory mechanism to maintain cardiac output.

💧 Effective IV fluid therapy restores intravascular volume, reducing sympathetic stimulation.

💧 As preload improves, the heart no longer needs to beat as fast to perfuse tissues.

💧 This physiologic response is a clear and early sign of successful volume resuscitation.

❌ Incorrect Options

❌ Increase in hematocrit: Fluid replacement causes hemodilution, which lowers hematocrit, not increases it. An increase suggests worsening hypovolemia.

❌ Increase in respiratory rate: Tachypnea may indicate distress or acidosis. It does not reflect improved volume status.

❌ Decrease in capillary refill time: Although improved refill is helpful, it is less specific than heart rate for evaluating intravascular volume restoration.

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Answer 2

Correct Answers:

"Would you like it if we discussed the transfer with your family member?"

Rationale :

🗣️ This response promotes client autonomy and family involvement in care decisions.

🗣️ It invites collaboration and respects the client’s right to participate in planning.

🗣️ Open-ended phrasing encourages shared decision-making rather than authority-based explanations.

🗣️ The nurse maintains professionalism while supporting clear communication.

🗣️ This approach aligns with ethical and therapeutic communication principles.

❌ Incorrect Options

❌ “The provider knows what’s best.” This is dismissive and discourages questions. It undermines trust and shared decision-making.

❌ “Why are you so concerned?” This sounds defensive and may make the family feel judged. It is not therapeutic.

❌ Personal disclosure about the nurse’s parent: This shifts focus away from the client and family. It is inappropriate self-disclosure.

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Answer 3

Correct Answers:

Potassium 5.8 mEq/L (3.5 to 5 mEq/L)

Rationale :

⚠️ A potassium level of 5.8 mEq/L indicates hyperkalemia, which can cause life-threatening cardiac dysrhythmias.

⚠️ Electrolyte abnormalities affecting the heart are always high priority.

⚠️ Hypovolemia can impair renal perfusion, reducing potassium excretion.

⚠️ Untreated hyperkalemia may progress to ventricular arrhythmias or cardiac arrest.

⚠️ This finding requires immediate provider notification and intervention.

❌ Incorrect Options

❌ BUN 21 mg/dL: This is only slightly elevated and expected with dehydration. It is not immediately dangerous.

❌ Creatinine 1.4 mg/dL: This suggests reduced renal perfusion but is not as immediately life-threatening as hyperkalemia.

❌ Sodium 132 mEq/L: Mild hyponatremia requires monitoring but does not pose an acute cardiac risk.

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Answer 4

Correct Answers:

"Maintain a consistent time to wake up each day."

Rationale :

🌙 Maintaining a consistent wake-up time helps regulate the body’s circadian rhythm, which controls sleep–wake cycles.

🌙 Waking at the same time daily strengthens sleep drive and improves the ability to fall asleep at night.

🌙 Consistency reinforces natural melatonin release, promoting restorative sleep.

🌙 This strategy is a cornerstone of evidence-based sleep hygiene.

🌙 Over time, regular wake times improve sleep onset and sleep quality.

❌ Incorrect Options

❌ Drink a cup of hot cocoa before bedtime: Cocoa contains caffeine, which can stimulate the nervous system and delay sleep onset. Warm beverages may also increase nighttime awakenings due to urination.

❌ Exercise 1 hour before going to bed: Late-evening exercise increases alertness and core body temperature, making it harder to fall asleep. Exercise is best earlier in the day.

❌ Watch television in bed before sleeping: Screen exposure emits blue light, which suppresses melatonin. Bedtime screen use is associated with delayed sleep onset.

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Answer 5

Correct Answers:

Pad the client's wrist before applying the restraints.

Rationale :

🔒 Padding the wrists protects the skin from pressure, friction, and breakdown caused by restraints.

🔒 Restraints increase the risk for impaired circulation, nerve injury, and skin damage, making padding essential.

🔒 Proper padding helps maintain client safety and comfort while the restraint is in use.

🔒 Nursing standards require using the least restrictive and safest method when restraints are necessary.

🔒 This action demonstrates appropriate restraint application and injury prevention.

❌ Incorrect Options

❌ Evaluate circulation every 8 hr: Circulation must be assessed at least every 2 hr, not every 8 hr. Longer intervals increase the risk of ischemia.

❌ Remove restraints every 4 hr: Restraints should be removed at least every 2 hr to assess the client and provide range of motion.

❌ Secure restraint ties to the bed’s side rails: Restraints must be tied to the bed frame, not side rails, to prevent injury if rails move.

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Answer 6

Correct Answers:

Evacuate the client.

Rationale :

🔥 Once a fire is confirmed, client safety is the top priority, especially for a nonambulatory client.

🔥 According to the RACE protocol, evacuation occurs after rescue and before confining or extinguishing the fire.

🔥 Removing the client from immediate danger prevents burn injury and smoke inhalation.

🔥 Nonambulatory clients cannot self-rescue and depend entirely on nursing action.

🔥 This step aligns with fire safety standards and emergency preparedness.

❌ Incorrect Options

❌ Activate the emergency fire alarm: The alarm should be activated, but rescuing the client comes first.

❌ Extinguish the fire: Firefighting is not the priority when a client is in danger. Safety outweighs property protection.

❌ Confine the fire: Closing doors limits spread but must occur after the client is safe.

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Answer 7

Correct Answers:

107

Rationale :

🧮 The total volume to infuse is 750 mL over 7 hours.

🧮 Divide the volume by time: 750 ÷ 7 = 107.14 mL/hr.

🧮 Round to the nearest whole number to match pump settings.

🧮 107 mL/hr is the correct rate to deliver the prescribed fluid safely.

Calculation (for revision):

🧮 750 mL ÷ 7 hr = 107.14 → 107 mL/hr

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Answer 8

Correct Answers:

Ensure the bladder of the blood pressure cuff surrounds 80% of the client's arm.

Rationale :

🩺 Using a blood pressure cuff with a bladder that surrounds approximately 80% of the arm circumference ensures accurate blood pressure measurement.

🩺 An appropriately sized cuff prevents false high or false low readings.

🩺 Undersized cuffs can overestimate blood pressure, while oversized cuffs can underestimate it.

🩺 Accurate vital signs are essential for clinical decision-making and patient safety.

🩺 This technique reflects evidence-based assessment practice.

❌ Incorrect Options

❌ Use the FLACC pain scale: FLACC is designed for infants and young children, not adult clients. Adults should use self-report pain scales.

❌ Auscultate the apical heart rate at the third intercostal space: The apical pulse is auscultated at the fifth intercostal space, left midclavicular line, not the third.

❌ Palpate the abdomen before auscultation: The correct sequence is inspection, auscultation, percussion, then palpation to avoid altering bowel sounds.

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Answer 9

Correct Answers:

"We can talk about advance directives, and I can also give you some brochures about them."

Rationale :

🕊️ This response acknowledges the client’s request and supports autonomy and informed decision-making.

🕊️ It offers both verbal discussion and written resources, accommodating different learning preferences.

🕊️ Nurses are responsible for providing information about advance directives, even if providers complete the forms.

🕊️ Addressing the topic when the client initiates it respects their readiness and emotional needs.

🕊️ This approach reflects therapeutic, patient-centered communication.

❌ Incorrect Options

❌ “Talk to your provider.” This deflects the client’s request and delays education the nurse can provide now.

❌ “Let’s save planning for later.” This dismisses the client’s expressed concern and may increase anxiety.

❌ Questioning why the partner is not present: This is intrusive and judgmental, violating client autonomy.

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Answer 10

Correct Answers:

During the admission process

Rationale :

❤️ Discharge planning begins at admission to ensure continuity of care and reduce readmission risk.

❤️ Clients with heart failure require early planning for medications, diet, activity, and follow-up care.

❤️ Early planning allows time to identify barriers such as transportation, finances, or home support.

❤️ Education is more effective when provided throughout hospitalization, not just at discharge.

❤️ This proactive approach improves outcomes and self-management.

❌ Incorrect Options

❌ After the condition is stable: Waiting delays education and coordination. Planning should not be postponed.

❌ During the initial team conference: Conferences support planning but do not replace early initiation.

❌ After consulting the family: Family input is valuable, but planning starts regardless of consultation timing.

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QLexNursing

1 :
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

2 :
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

3 :
A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse report to the provider?

4 :
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

5 :
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

6 :
A client who is non ambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

7 :
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 :
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

9 :
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

❌ Incorrect Options

10 :
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

QLexNursing

1 : A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

2 : A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

3 : A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse report to the provider?

4 : A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

5 : A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

6 : A client who is non ambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

7 : A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 : A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

9 : A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

❌ Incorrect Options

10 : A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?

1 :
A nurse is administering 1 L of 0.9% sodium chloride to a client who is postoperative and has fluid volume deficit. Which of the following changes should the nurse identify as an indication that the treatment was successful?

2 :
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following responses made by the nurse is appropriate?

3 :
A nurse is reviewing the laboratory results of a female client who has hypovolemia. Which of the following laboratory result would be a priority for the nurse report to the provider?

4 :
A nurse is caring for a client who reports difficulty falling asleep. Which of the following recommendations should the nurse make?

5 :
A nurse on a medical-surgical unit is caring for a client who has a new prescription for wrist restraints. Which of the following actions should the nurse take?

6 :
A client who is non ambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?

7 :
A nurse is preparing to administer 0.9% sodium chloride 750 mL IV to infuse over 7 hr. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

8 :
A nurse is assessing four adult clients. Which of the following physical assessment techniques should the nurse use?

9 :
A nurse is caring for a client who has a terminal diagnosis and whose health is declining. The client requests information about advance directives. Which of the following responses should the nurse make?

10 :
A nurse is admitting a client who is having an exacerbation of heart failure. In planning this client's care, when should the nurse initiate discharge planning?