Nursing Elites

1. When assessing a client with a diagnosis of bipolar disorder who reports taking a handful of medications, what information is most important to obtain?

• A. What drugs the client used in the suicide attempt.
• B. When the client last took medications for bipolar disorder.
• C. Whether the client has attempted suicide before.
• D. Which family member has the suicide note.

Correct answer: A

Rationale: The correct answer is to obtain information on what drugs the client used in the suicide attempt. This information is crucial for assessing the severity of the overdose, potential drug interactions, and determining the appropriate treatment plan. Choice B is not as urgent as identifying the drugs taken during the suicide attempt. Choice C, while important, is not as immediately critical as knowing the specific medications involved. Choice D is unrelated to the immediate medical needs of the client.

2. A client receiving continuous ambulatory peritoneal dialysis (CAPD) has lost weight and exhibits increasing edema. What should the nurse prioritize?

• A. Evaluate the patency of the arteriovenous (AV) graft.
• B. Instruct the client to continue a fluid-restricted diet.
• C. Recommend support stockings for venous return.
• D. Monitor the client's serum albumin levels.

Correct answer: A

Rationale: In a client receiving continuous ambulatory peritoneal dialysis (CAPD) who has lost weight and exhibits increasing edema, the nurse should prioritize evaluating the patency of the arteriovenous (AV) graft. This assessment is crucial to determine if hemodialysis can be resumed, addressing the client's presenting issues effectively. Instructing the client to continue a fluid-restricted diet (choice B) may not address the underlying issue related to the CAPD. Recommending support stockings for venous return (choice C) is not directly relevant to the situation described. Monitoring the client's serum albumin levels (choice D) may be important but does not directly address the immediate concern of weight loss and increasing edema in a CAPD client.

3. A client with a history of type 2 diabetes is admitted with hyperglycemia. What is the nurse's priority action?

• A. Administer a dose of insulin as prescribed.
• B. Check the client's blood glucose level.
• C. Administer a fluid bolus to improve hydration.
• D. Monitor the client's intake and output closely.

Correct answer: B

Rationale: The correct answer is to check the client's blood glucose level. This is the priority action when dealing with a client admitted with hyperglycemia. Checking the blood glucose level helps determine the severity of hyperglycemia and guides further treatment. Administering insulin or fluids or monitoring intake and output are important interventions but should come after assessing the blood glucose level to inform the most appropriate course of action.

4. A client with chronic obstructive pulmonary disease (COPD) is receiving supplemental oxygen. The client reports feeling short of breath and has a respiratory rate of 28 breaths per minute. What should the nurse do first?

• A. Increase the oxygen flow rate
• B. Notify the healthcare provider
• C. Administer a bronchodilator
• D. Elevate the head of the bed

Correct answer: D

Rationale: Elevating the head of the bed promotes lung expansion and improves oxygenation, making it the priority intervention for a client with shortness of breath. This position helps in maximizing lung expansion and aiding ventilation-perfusion matching in patients with COPD. Increasing the oxygen flow rate may be necessary but should come after optimizing the client's positioning. Notifying the healthcare provider and administering a bronchodilator are not the initial interventions for addressing shortness of breath in a client with COPD.

5. A client with Cushing's syndrome presents with excessive bruising and elevated blood glucose. What action should the nurse take first?

• A. Check the client's blood glucose level.
• B. Administer insulin per sliding scale protocol.
• C. Administer intravenous fluids.
• D. Check the client's skin for signs of bruising.

Correct answer: A

Rationale: Excessive bruising and elevated blood glucose are common symptoms of Cushing's syndrome. The nurse should first check the client's blood glucose level to assess and address the hyperglycemia promptly. Administering insulin or IV fluids would be premature without knowing the current blood glucose level. Checking the skin for bruising, although important for overall assessment, does not address the immediate concern of elevated blood glucose.

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