Nursing Elites

1. A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer intravenous fluids as prescribed.
• B. Administer insulin as prescribed.
• C. Monitor the client's urine output.
• D. Check the client's blood glucose level.

Correct answer: B

Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. Insulin helps to reduce blood glucose levels and correct metabolic acidosis, which are critical in the treatment of DKA. While administering intravenous fluids is essential to manage dehydration, insulin takes precedence in treating the underlying cause of DKA. Monitoring urine output is important for assessing renal function but is not the primary intervention in managing DKA. Checking the client's blood glucose level is necessary, but administering insulin to reduce high blood glucose levels is the key priority in treating DKA.

2. A client with hyperthyroidism is admitted to the postoperative unit after subtotal thyroidectomy. Which of the client's serum laboratory values requires intervention by the nurse?

• A. Total calcium 5.0 mg/dL.
• B. Serum sodium 140 mEq/L.
• C. Serum potassium 4.0 mEq/L.
• D. Serum glucose 90 mg/dL.

Correct answer: A

Rationale: The correct answer is A. A calcium level of 5.0 mg/dL is critically low and could indicate hypoparathyroidism, a possible complication after thyroidectomy. Low calcium levels can lead to tetany, seizures, and cardiac dysrhythmias, requiring immediate intervention. Choices B, C, and D fall within the normal range and do not require immediate intervention in this scenario.

3. One day after abdominal surgery, an obese client complains of pain and heaviness in the right calf. What action should the nurse implement?

• A. Observe for unilateral swelling
• B. Administer pain medication
• C. Elevate the leg and apply a warm compress
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to implement is to observe for unilateral swelling. Unilateral swelling could indicate a deep vein thrombosis (DVT), which is a serious complication that requires immediate assessment. Administering pain medication or applying warm compress may not address the underlying cause of the symptoms. Notifying the healthcare provider should be done after assessing and identifying the issue of unilateral swelling.

4. A client who has just returned from surgery is shivering uncontrollably. What is the best action for the nurse to take?

• A. Offer the client a warm blanket
• B. Apply warm blankets and monitor the client's temperature
• C. Place a warm blanket in the client's bed before transferring the client from the stretcher
• D. Administer a prescribed muscle relaxant

Correct answer: B

Rationale: Applying warm blankets and monitoring the client's temperature is the best action to manage postoperative shivering. Shivering after surgery can be a common response due to factors like exposure to cold, pain, or anesthesia effects. Providing warmth through blankets can help regulate the client's body temperature and alleviate shivering. Monitoring the client's temperature is essential to ensure it returns to a normal range. Option A is not as comprehensive as option B, which includes both providing warmth and monitoring the client. Option C is incorrect as it focuses on preparing the bed rather than addressing the client's immediate need for warmth. Option D is not appropriate without further assessment or prescription for a muscle relaxant to address shivering.

5. A 75-year-old female client is admitted to the orthopedic unit following an open reduction and internal fixation of a hip fracture. On the second postoperative day, the client becomes confused and repeatedly asks the nurse where she is. What information is most important for the nurse to obtain?

• A. History of alcohol use
• B. Current medication list
• C. Baseline cognitive status
• D. Family history of dementia

Correct answer: A

Rationale: The correct answer is A: History of alcohol use. In this scenario, obtaining the history of alcohol use is crucial as it could indicate withdrawal, which might explain the client's confusion. Alcohol withdrawal can lead to symptoms such as confusion, agitation, and disorientation. While knowing the current medication list (choice B) is important for overall patient care, in this case, alcohol withdrawal is a more likely cause of the confusion. Baseline cognitive status (choice C) is valuable for comparison but may not directly explain the sudden confusion. Family history of dementia (choice D) is less relevant in this acute situation compared to the potential immediate impact of alcohol withdrawal.

Similar Questions