Nursing Elites

1. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?

• A. Administer intravenous insulin as prescribed.
• B. Monitor the client's urine output.
• C. Administer intravenous fluids.
• D. Administer 50% dextrose IV push.

Correct answer: A

Rationale: Administering intravenous insulin is the initial priority in managing diabetic ketoacidosis (DKA). Insulin helps to reduce blood glucose levels and correct metabolic acidosis, addressing the underlying cause of DKA. Monitoring urine output (choice B) is important but is not the first intervention needed. Administering intravenous fluids (choice C) is essential to correct dehydration in DKA, but insulin therapy takes precedence. Administering 50% dextrose IV push (choice D) is contraindicated in DKA as it can exacerbate hyperglycemia.

2. A client with a spinal cord injury is admitted to the ICU. Which nursing intervention is most important to include in this client's plan of care?

• A. Monitor for signs of autonomic dysreflexia.
• B. Implement measures to prevent pressure ulcers.
• C. Perform passive range of motion exercises.
• D. Ensure that the client is turned every two hours.

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of autonomic dysreflexia. Autonomic dysreflexia is a life-threatening condition that can occur in clients with spinal cord injuries, especially those with injuries above the T6 level. It is characterized by a sudden onset of excessively high blood pressure, pounding headache, profuse sweating, and flushing above the level of injury. Failure to recognize and treat autonomic dysreflexia promptly can lead to seizures, stroke, or even death. Therefore, monitoring for signs of autonomic dysreflexia is crucial in clients with spinal cord injuries. Choices B, C, and D are important interventions too, but in the context of a spinal cord injury, monitoring for autonomic dysreflexia takes priority due to its potentially life-threatening nature.

3. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?

• A. A client with congestive heart failure who reports a 3-pound weight gain in the last two days
• B. A client with a healing surgical wound
• C. A client requiring wound dressing change
• D. A client with stable vital signs needing medication administration

Correct answer: A

Rationale: The correct answer is A. A 3-pound weight gain in two days indicates fluid retention and worsening heart failure, which requires immediate assessment. This could be a sign of decompensation in the client's condition, necessitating prompt evaluation and intervention. Choices B, C, and D do not present an immediate threat to the client's health and can be addressed after assessing the client with congestive heart failure.

4. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which clinical finding is most concerning?

• A. Headache
• B. Prothrombin time (PT) of 15 seconds
• C. Elevated liver enzymes
• D. Peripheral edema

Correct answer: A

Rationale: The correct answer is A: Headache. In a client with atrial fibrillation taking warfarin (Coumadin), a headache can be indicative of bleeding, which is a serious complication requiring immediate assessment and intervention. Monitoring for signs of bleeding is crucial when on anticoagulant therapy. Choices B, C, and D are not the most concerning. A prothrombin time of 15 seconds is within the therapeutic range for a client on warfarin, elevated liver enzymes may indicate liver dysfunction but are not directly related to the medication's side effects, and peripheral edema is not typically associated with warfarin use or atrial fibrillation in this context.

5. The nurse is caring for a client with a history of myocardial infarction who is complaining of chest pain. Which intervention should the nurse implement first?

• A. Administer oxygen therapy as prescribed.
• B. Administer nitroglycerin sublingually as prescribed.
• C. Obtain an electrocardiogram (ECG).
• D. Assess the client's level of consciousness.

Correct answer: C

Rationale: Obtaining an electrocardiogram (ECG) is the first priority in assessing for ischemia or infarction in a client with chest pain and a history of myocardial infarction. This diagnostic test provides crucial information about the heart's electrical activity and helps in identifying any acute cardiac changes. Administering oxygen therapy and nitroglycerin can be important interventions, but obtaining an ECG takes precedence as it directly assesses the client's cardiac status. Assessing the client's level of consciousness is also essential, but in this scenario, assessing for cardiac indications through an ECG is the initial step.

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