Nursing Elites

1. 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.

2. A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?

• A. Assess for signs of infection.
• B. Monitor the client’s fluid intake and output.
• C. Check the client’s capillary blood glucose level.
• D. Assess the client’s serum potassium level.

Correct answer: C

Rationale: The correct answer is to check the client’s capillary blood glucose level first. In a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, assessing blood glucose levels is crucial to confirm hyperglycemia and initiate appropriate interventions. While signs of infection are important to assess due to the client's postoperative status and diabetic history, checking the blood glucose level takes precedence to address the immediate concern of hyperglycemia. Monitoring fluid intake and output is essential but not the priority in this scenario. Assessing the client’s serum potassium level is important for overall assessment but not the initial step when hyperglycemia is suspected.

3. A client with a history of deep vein thrombosis (DVT) is prescribed warfarin. Which laboratory value should the nurse monitor to assess the therapeutic effect of this medication?

• A. Platelet count
• B. Prothrombin time (PT)
• C. White blood cell count
• D. Hemoglobin level

Correct answer: B

Rationale: Prothrombin time (PT) is the correct laboratory value to monitor to assess the therapeutic effect of warfarin. Warfarin works by inhibiting clotting factors, and PT measures the time it takes for blood to clot. Monitoring PT helps ensure that the medication is working effectively to prevent clot formation without causing excessive bleeding. Platelet count (Choice A) is not specific to warfarin therapy and assesses the number of platelets in the blood. White blood cell count (Choice C) and hemoglobin level (Choice D) are not directly related to monitoring the therapeutic effect of warfarin.

4. A client is admitted with a large pleural effusion. Which procedure should the nurse prepare the client for?

• A. Thoracentesis.
• B. Endotracheal intubation.
• C. Chest tube insertion.
• D. Bronchoscopy.

Correct answer: A

Rationale: Corrected Rationale: The correct procedure for a client with a large pleural effusion is thoracentesis. Thoracentesis is a diagnostic and therapeutic procedure used to remove fluid from the pleural space, which can help relieve symptoms associated with pleural effusion. Choice B (Endotracheal intubation) is incorrect as it is a procedure to secure the airway by placing a tube into the trachea. Choice C (Chest tube insertion) is incorrect as it is typically done to drain air or fluid from the pleural space over a longer period. Choice D (Bronchoscopy) is incorrect as it is a procedure used to visualize the airways and diagnose lung conditions, not specifically for pleural effusion removal.

5. At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

• A. Cancel the surgery
• B. Inform the anesthesia care provider
• C. Ask the client if she has had any other liquids
• D. Proceed with routine preparations

Correct answer: B

Rationale: Drinking liquids before surgery can increase the risk of aspiration during anesthesia. Therefore, the anesthesia care provider must be informed immediately to determine how to proceed, as this could delay or alter the surgical plan. Canceling the surgery without consulting the anesthesia care provider would be premature and could potentially lead to unnecessary actions. Asking the client if she has had any other liquids is important but not the first priority. Proceeding with routine preparations without addressing the potential issue of ingesting liquids before surgery could compromise the client's safety.

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