Nursing Elites

1. A client is admitted with diabetic ketoacidosis (DKA). Which assessment finding requires immediate intervention?

• A. Fruity breath odor.
• B. Blood glucose of 450 mg/dL.
• C. Deep, rapid respirations.
• D. Serum potassium of 5.2 mEq/L.

Correct answer: C

Rationale: The correct answer is C: Deep, rapid respirations (Kussmaul breathing). This is a sign of severe acidosis commonly seen in diabetic ketoacidosis (DKA) and requires immediate intervention. Kussmaul breathing helps to compensate for the metabolic acidosis by blowing off carbon dioxide. Prompt intervention is necessary to prevent further deterioration and potential respiratory failure. Fruity breath odor (Choice A) is a classic sign of DKA but does not require immediate intervention. While a blood glucose level of 450 mg/dL (Choice B) is high, it does not pose an immediate threat to the client's life. Serum potassium of 5.2 mEq/L (Choice D) is slightly elevated but not the most critical finding that requires immediate intervention in this scenario.

2. A client with a history of gout is experiencing an acute attack. Which medication should the nurse expect the healthcare provider to prescribe?

• A. Aspirin.
• B. Allopurinol (Zyloprim).
• C. Colchicine.
• D. Probenecid (Benemid).

Correct answer: C

Rationale: During an acute gout attack, the healthcare provider is likely to prescribe colchicine. Colchicine is commonly used to treat acute gout attacks because it works by reducing inflammation and alleviating pain associated with the condition. It is important to note that aspirin is not recommended for gout treatment and may even exacerbate the symptoms. Allopurinol and probenecid are medications used for long-term management of gout by reducing uric acid levels in the blood, but they are not typically prescribed during an acute attack. Therefore, colchicine is the most appropriate medication for managing an acute gout attack.

3. Which problem in a client requires the most immediate intervention by the nurse?

• A. Finger paresthesias related to carpal tunnel syndrome.
• B. Increasing sharp pain related to compartment syndrome.
• C. Increasing burning pain related to a Morton's neuroma.
• D. Increasing sharp pain related to plantar fasciitis.

Correct answer: B

Rationale: The correct answer is B: Increasing sharp pain related to compartment syndrome. Compartment syndrome is a serious condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. Immediate intervention is crucial to prevent permanent damage to muscles and nerves, including tissue necrosis and nerve injury. Choices A, C, and D do not present the same level of urgency as compartment syndrome, making them less critical for immediate intervention. Carpal tunnel syndrome, Morton's neuroma, and plantar fasciitis may cause discomfort and functional limitations but are not typically considered emergencies requiring urgent intervention like compartment syndrome.

4. A patient with atrial fibrillation is prescribed warfarin. Which laboratory test should the nurse monitor to assess the effectiveness of the medication?

• A. Complete blood count (CBC)
• B. Prothrombin time (PT)/INR
• C. Partial thromboplastin time (PTT)
• D. Serum potassium level

Correct answer: B

Rationale: The correct answer is B: Prothrombin time (PT)/INR. Warfarin affects the clotting ability of the blood by inhibiting vitamin K-dependent clotting factors. Monitoring the prothrombin time (PT) and international normalized ratio (INR) is crucial to assess the effectiveness and safety of warfarin therapy. These tests help determine if the patient is within the desired anticoagulation range to prevent either clotting issues or excessive bleeding.

5. What nursing intervention can help alleviate pruritus in a client with cirrhosis?

• A. Administering antihistamines
• B. Providing a high-protein diet
• C. Applying emollients to the skin
• D. Encouraging frequent baths with hot water

Correct answer: C

Rationale: Applying emollients to the skin can help alleviate pruritus in clients with cirrhosis. Emollients help soothe and moisturize the skin, reducing the discomfort associated with itching.

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