Nursing Elites

1. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which intervention should the nurse implement first?

• A. Administer 50% dextrose IV push
• B. Administer IV fluids as prescribed
• C. Check the client's blood glucose level
• D. Prepare the client for immediate dialysis

Correct answer: B

Rationale: Administering IV fluids as prescribed should be the first intervention for a client with diabetes mellitus admitted with a blood glucose level of 600 mg/dl and unresponsive. This intervention is crucial in managing hyperglycemia by helping to correct dehydration and electrolyte imbalances. Administering 50% dextrose IV push (Choice A) would worsen hyperglycemia in this scenario. Checking the client's blood glucose level (Choice C) is important but not the priority when dealing with an unresponsive client with severe hyperglycemia. Immediate dialysis preparation (Choice D) is not indicated as the first intervention for hyperglycemia.

2. A client with diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which laboratory value is most concerning?

• A. Serum potassium of 3.0 mEq/L
• B. Serum glucose of 200 mg/dl
• C. Serum pH of 7.30
• D. Serum sodium of 135 mEq/L

Correct answer: C

Rationale: In a client with Hyperosmolar Hyperglycemic State (HHS), a serum pH of 7.30 is the most concerning value as it indicates acidosis, a life-threatening condition that requires immediate intervention. Choices A, B, and D are not the most concerning in this scenario. A low serum potassium level (Choice A) may be expected due to cellular shift in hyperglycemia, a serum glucose level of 200 mg/dl (Choice B) is not as concerning compared to the extremely high initial glucose level, and a serum sodium level of 135 mEq/L (Choice D) is within the normal range and not the immediate priority.

3. An 11-year-old client is admitted to the mental health unit after trying to run away from home and threatening self-harm. The nurse establishes a goal to promote effective coping and plans to ask the client to verbalize three ways to deal with stress. Which activity is best to establish rapport and accomplish this therapeutic goal?

• A. Play a board game with the client and begin talking about stressors
• B. Conduct a formal therapy session
• C. Ask the client to write down their feelings
• D. Have a group discussion about stress management

Correct answer: A

Rationale: Playing a board game with the client and initiating a conversation about stressors is the best choice to establish rapport and achieve the therapeutic goal of helping the client verbalize ways to cope with stress. Board games provide a relaxed and non-threatening environment, allowing the client to feel more comfortable and open up about their stressors. Choice B, conducting a formal therapy session, might be too structured and intimidating for the client, hindering open communication. Choice C, asking the client to write down their feelings, lacks the interactive and engaging aspect that a board game provides. Choice D, having a group discussion about stress management, may not be as effective initially as one-on-one interaction to build trust and rapport with the client.

4. A female client with type 2 diabetes reports that she has been taking her medications as prescribed but her blood glucose levels remain elevated. Which action should the nurse take first?

• A. Check the client's current blood glucose level.
• B. Assess the client's diet and medication adherence.
• C. Review the client's medication list for potential interactions.
• D. Obtain a hemoglobin A1c level.

Correct answer: C

Rationale: The correct action the nurse should take first is to review the client's medication list for potential interactions. This step is crucial as it can help identify any medications that might be contributing to the elevated blood glucose levels. Checking the current blood glucose level (choice A) is important but not the first action to address the ongoing issue. Assessing the client's diet and medication adherence (choice B) is also important, but reviewing the medication list should be the initial step to rule out any drug-related causes. Obtaining a hemoglobin A1c level (choice D) is a valuable assessment but may not address the immediate need to identify potential medication interactions.

5. A client with a history of chronic alcoholism is admitted with confusion, ataxia, and diplopia. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is to administer thiamine as prescribed. This intervention is a priority for clients with chronic alcoholism to prevent Wernicke's encephalopathy, a serious complication of thiamine deficiency. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority in this scenario. Providing a quiet environment (choice C) may be beneficial but does not address the immediate need to prevent Wernicke's encephalopathy. Initiating fall precautions (choice D) is also important but not the priority compared to administering thiamine to prevent a life-threatening condition.

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