Nursing Elites

1. A client with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?

• A. Administer intravenous insulin.
• B. Start an intravenous fluid bolus.
• C. Obtain a blood glucose level.
• D. Administer an antiemetic.

Correct answer: B

Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.

2. A client who is bedridden after a stroke is at risk for developing pressure ulcers. Which nursing intervention is most important in preventing this complication?

• A. Apply lotion to the skin every 4 hours.
• B. Reposition the client every 2 hours.
• C. Elevate the head of the bed 30 degrees.
• D. Massage the skin at least twice a day.

Correct answer: B

Rationale: Repositioning the client every 2 hours is crucial in preventing pressure ulcers in bedridden clients. This intervention helps in relieving pressure on specific areas of the body, promoting circulation, and reducing the risk of tissue damage. Applying lotion every 4 hours (Choice A) may not address the root cause of pressure ulcers. Elevating the head of the bed (Choice C) is beneficial for some conditions but not specifically targeted at preventing pressure ulcers. Massaging the skin at least twice a day (Choice D) can actually increase the risk of skin breakdown in individuals at risk for pressure ulcers by causing friction and shearing forces on the skin.

3. A nurse is caring for a client with a chest tube following lung surgery. What is the most important intervention to ensure the chest tube functions properly?

• A. Clamp the tube if there is excessive drainage
• B. Empty the drainage chamber every 2 hours
• C. Keep the drainage system below chest level
• D. Milk the tube to prevent clots from forming

Correct answer: C

Rationale: The correct answer is C. Keeping the chest tube drainage system below chest level ensures that gravity assists with drainage and prevents fluid or air from flowing back into the pleural space, which could compromise lung function. Clamping the tube if there is excessive drainage (choice A) is incorrect as it can lead to a buildup of pressure and compromise the drainage system. Emptying the drainage chamber every 2 hours (choice B) is important but not as crucial as maintaining the drainage system below chest level. Milking the tube to prevent clots from forming (choice D) is incorrect and could lead to complications such as tube occlusion or damage to the tissue.

4. The healthcare provider prescribes celtazidime for an infant, IM, every 8 hours. The vial is 500 mg with a concentration of 100 mg/ml after reconstitution. How many ml should the nurse administer?

• A. 3 ml.
• B. 0.4 ml.
• C. 1.2 ml.
• D. 0.9 ml.

Correct answer: B

Rationale: To administer 35 mg of celtazidime from a 100 mg/ml solution, the nurse should give 0.4 ml of the reconstituted celtazidime solution. The calculation is 35 mg / 100 mg/ml = 0.35 ml, but since the vial is 500 mg, the answer is 0.35 ml * (500 mg / 100 mg) = 0.4 ml. Therefore, choices A, C, and D are incorrect as they do not reflect the correct calculation based on the provided information.

5. A client with peripheral artery disease reports leg cramps while walking. What intervention should the nurse recommend?

• A. Encourage the client to rest immediately when cramping occurs.
• B. Recommend that the client increase their intake of potassium-rich foods.
• C. Advise the client to take a short break, then continue walking.
• D. Recommend that the client avoid walking altogether to prevent cramps.

Correct answer: C

Rationale: For clients with peripheral artery disease, advising the client to take a short break when leg cramps occur and then continue walking is the appropriate intervention. This approach, known as interval walking, helps manage pain from intermittent claudication and improves circulation over time. Choice A is incorrect because immediate rest may not be necessary, and encouraging the client to resume walking after a short break is more beneficial. Choice B is incorrect since increasing potassium-rich foods may not directly address the underlying issue of peripheral artery disease causing cramps. Choice D is incorrect as avoiding walking altogether can lead to further deconditioning and worsen symptoms over time.

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