Nursing Elites

1. A client with renal disease seems anxious and presents with the onset of shortness of breath, lethargy, edema, and weight gain. Which action should the nurse implement first?

• A. Determine serum potassium level
• B. Calculate the client’s daily fluid intake
• C. Assess client for signs of vertigo
• D. Review the client’s pulse oximetry reading

Correct answer: A

Rationale: The correct answer is to determine the client's serum potassium level. In a client with renal disease experiencing symptoms like shortness of breath, lethargy, edema, and weight gain, assessing serum potassium levels is crucial. Electrolyte imbalances, including potassium, can lead to serious complications such as cardiac arrhythmias and muscle weakness. Calculating daily fluid intake may be important but addressing acute symptoms related to electrolyte imbalances takes precedence. Assessing for signs of vertigo and reviewing pulse oximetry reading are not the priority in this scenario compared to assessing and managing potential electrolyte imbalances.

2. A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Restrict daily fluid intake to 1500 ml
• B. Weight the client every morning
• C. Maintain accurate intake and output
• D. Administer prescribed diuretic

Correct answer: D

Rationale: Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.

3. A 13-year-old girl, diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

• A. Ate an extra peanut butter sandwich before gym class
• B. Incorrectly drew up and administered too much insulin
• C. Was not hungry, so she skipped eating lunch
• D. Has had a cold and ear infection for the past two days

Correct answer: B

Rationale: The correct answer is B. Incorrect insulin administration is a common cause of diabetic ketoacidosis. Administering too much insulin can lead to uncontrolled hyperglycemia, where the body starts breaking down fat for energy, resulting in the production of ketones. Choices A, C, and D are less likely to directly cause diabetic ketoacidosis. Eating an extra peanut butter sandwich, skipping lunch, or having a cold and ear infection would not directly lead to the metabolic derangements seen in diabetic ketoacidosis.

4. When caring for a client with diabetes insipidus (DI), it is most important for the nurse to include frequent assessment for which conditions in the client’s plan of care?

• A. Dry mucous membranes, hypotension
• B. Decreased appetite, headache
• C. Nausea and vomiting, muscle weakness
• D. Elevated blood pressure, petechiae

Correct answer: A

Rationale: Dry mucous membranes and hypotension are key indicators of dehydration in clients with diabetes insipidus. The excessive urination associated with DI can lead to fluid loss, resulting in dehydration. Therefore, monitoring for signs such as dry mucous membranes and hypotension is crucial to assess the client's hydration status. Choices B, C, and D are not directly related to the characteristic symptoms of DI and are less relevant in the context of this condition. Decreased appetite and headache (Choice B) are nonspecific symptoms that may occur in various conditions. Nausea, vomiting, and muscle weakness (Choice C) are not typical manifestations of DI. Elevated blood pressure and petechiae (Choice D) are not commonly associated with DI; instead, hypotension is more commonly observed due to volume depletion.

5. The nurse is assessing an older adult with type 2 diabetes. Which assessment finding indicates that the client understands long-term control of diabetes?

• A. The fasting blood sugar was 120 mg/dL this morning
• B. Urine ketones have been negative for the past 6 months
• C. The hemoglobin A1C was 6.5% last week
• D. No diabetic ketoacidosis has occurred in 6 months

Correct answer: C

Rationale: An A1C level of 6.5% indicates good long-term control of diabetes as it reflects the average blood sugar levels over the past 2-3 months. Monitoring fasting blood sugar provides immediate information about the current blood sugar level, while the absence of urine ketones indicates short-term control. Although the absence of diabetic ketoacidosis is positive, it doesn't specifically reflect long-term control like the A1C level does.

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