Nursing Elites

1. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which assessment finding should the nurse anticipate?

• A. Oliguria.
• B. Kussmaul respirations.
• C. Fruity odor on the breath.
• D. Blood glucose level of 250 mg/dL.

Correct answer: B

Rationale: Kussmaul respirations (B) are a deep and labored breathing pattern associated with diabetic ketoacidosis (DKA) and are expected in this condition. While oliguria (A), fruity odor on the breath (C), and elevated blood glucose level (D) are also signs of DKA, Kussmaul respirations are more specific and critical to the condition, indicating severe metabolic acidosis.

2. What action should the nurse implement to prepare a client for the potential side effects of a newly prescribed medication?

• A. Assess the client for health alterations that may be impacted by the effects of the medication
• B. Teach the client how to administer the medication to promote the best absorption
• C. Administer a half dose and observe the client for side effects before administering a full dosage
• D. Encourage the client to drink plenty of fluids to promote effective drug distribution

Correct answer: A

Rationale: Before initiating a new medication, the nurse should conduct a thorough assessment of the client to identify any pre-existing health conditions or risk factors that could be affected by the medication. This assessment helps in establishing a baseline for monitoring potential side effects and determining the medication's appropriateness for the client. Choice B is incorrect as teaching the client how to administer the medication does not directly address preparing for potential side effects. Choice C is incorrect because administering a half dose without a proper assessment could be unsafe. Choice D is incorrect as encouraging fluid intake is not directly related to preparing for potential side effects of a medication.

3. What is the most effective way to implement a teaching plan?

• A. Teach the information that the learner wants to learn first.
• B. Streamline the teaching plan to include only essential information.
• C. Present to the learner all the necessary information to meet the objectives.
• D. Provide the learner with written material to review before teaching sessions.

Correct answer: A

Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.

4. When a client has suffered severe burns all over his body, the most effective method of monitoring the cardiovascular system is:

• A. Cuff blood pressure.
• B. Arterial pressure.
• C. Pulmonary artery pressure.
• D. Central venous pressure.

Correct answer: D

Rationale: Central venous pressure (CVP) monitoring is the most effective method to assess fluid status and the cardiovascular system in a client with severe burns. Severe burns can lead to significant fluid shifts and hemodynamic changes, making central venous pressure monitoring crucial for guiding fluid resuscitation and managing cardiovascular stability in these patients.

5. What intervention should the healthcare provider include in the plan of care for a client receiving treatment with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?

• A. Check capillary refill of toes on the lower extremity with the Unna's paste boot.
• B. Apply dressing to the wound area before applying the Unna's paste boot.
• C. Wrap the leg from the knee down towards the foot.
• D. Remove the Unna's paste boot every 8 hours to assess wound healing.

Correct answer: A

Rationale: When an Unna's paste boot is applied for leg ulcers due to chronic venous insufficiency, it is crucial to check the capillary refill of the toes on the lower extremity to ensure adequate circulation. The Unna's paste boot can become rigid after drying, potentially affecting circulation distally. Monitoring capillary refill helps assess the perfusion status of the distal extremity and ensures that the treatment is not compromising circulation to the toes.

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