Nursing Elites

1. 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.

2. 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.

3. At 0600 while admitting a woman for a scheduled repeat cesarean section (C-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. Ensure preoperative lab results are available
• B. Start prescribed IV with lactated Ringer's
• C. Inform the anesthesia care provider
• D. Contact the client's obstetrician

Correct answer: C

Rationale: The correct action for the nurse to take first is to inform the anesthesia care provider. The patient's ingestion of coffee violates the NPO (nothing by mouth) guidelines before surgery, which increases the risk of aspiration during anesthesia. Informing the anesthesia care provider promptly allows for appropriate assessment and decision-making regarding the patient's anesthesia plan. Ensuring preoperative lab results, starting an IV, or contacting the obstetrician can be important steps but addressing the NPO violation and its implications on anesthesia safety take precedence.

4. A client with newly diagnosed hypertension is being taught about lifestyle modifications by a nurse. Which client statement indicates a need for further teaching?

• A. ‘I will reduce my salt intake to help manage my blood pressure.’
• B. ‘I will start exercising regularly to help control my blood pressure.’
• C. ‘I will avoid drinking alcohol to help manage my blood pressure.’
• D. ‘I will limit my caffeine intake to help control my blood pressure.’

Correct answer: D

Rationale: The correct answer is D. Limiting caffeine intake is a positive lifestyle modification for managing hypertension. The statement indicates that the client understands the importance of reducing caffeine intake. Choices A, B, and C all reflect appropriate lifestyle modifications for managing hypertension, indicating good understanding by the client.

5. The mother of a one-month-old boy born at home brings the infant to his first well-baby visit. The infant was born two weeks after his due date and is described as a 'good, quiet baby' who almost never cries. To assess for hypothyroidism, what question is most important for the nurse to ask the mother?

• A. Has your son had any immunizations yet?
• B. Is your son sleepy and difficult to feed?
• C. Are you breastfeeding or bottle-feeding your son?
• D. Were any relatives born with birth defects?

Correct answer: B

Rationale: The correct answer is B. Excessive sleepiness and difficulty feeding can be signs of hypothyroidism in infants. Asking about the infant's sleepiness and feeding pattern is crucial in assessing for hypothyroidism. Choice A is incorrect because immunizations are not directly related to hypothyroidism. Choice C is about feeding method and not specific to hypothyroidism. Choice D is unrelated as it asks about relatives with birth defects, which does not directly assess the infant's condition.

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