Nursing Elites

1. A client with type 1 diabetes mellitus is experiencing nausea and vomiting. What is the most important instruction the nurse should provide?

• A. Stop taking insulin until feeling better
• B. Increase fluid intake to prevent dehydration
• C. Consume high-carbohydrate foods only
• D. Check blood glucose levels frequently

Correct answer: D

Rationale: The correct answer is to instruct the client to check blood glucose levels frequently. During illness, such as nausea and vomiting, managing blood glucose levels is crucial in clients with type 1 diabetes mellitus. Monitoring blood glucose levels frequently helps in adjusting insulin doses appropriately, preventing complications like hyperglycemia or hypoglycemia. Choice A is incorrect because stopping insulin abruptly can lead to serious complications. Choice B is important but not the most critical in this scenario. Choice C is incorrect as high-carbohydrate foods may further affect blood glucose levels negatively.

2. The nurse is obtaining a client's fingerstick glucose level. After gently milking the client's finger, the nurse observes that the distal tip of the finger appears reddened and engorged. What action should the nurse take?

• A. Collect the blood sample
• B. Assess radial pulse volume
• C. Apply pressure to the site
• D. Select another finger

Correct answer: A

Rationale: When the nurse observes that the distal tip of the client's finger is reddened and engorged after milking, it indicates adequate blood flow. At this point, the appropriate action is to collect the blood sample for glucose level testing. Assessing radial pulse volume (Choice B) is unrelated to the situation and not necessary. Applying pressure to the site (Choice C) may disrupt the blood sample collection process. Selecting another finger (Choice D) is not warranted as the engorgement indicates sufficient blood flow for sampling.

3. The nurse is caring for a newborn with a myelomeningocele. Before surgery, what should the nursing interventions include?

• A. Leaving the lesion uncovered and placing the infant supine
• B. Covering the lesion with a sterile, saline-soaked gauze
• C. Applying lotion to the lesion to keep it moist
• D. Covering the lesion with a dry, sterile gauze

Correct answer: B

Rationale: The correct intervention before surgery for a newborn with a myelomeningocele is to cover the lesion with a sterile, saline-soaked gauze. This helps protect the exposed spinal cord and meninges from infection and damage. Choice A is incorrect because leaving the lesion uncovered can increase the risk of infection. Choice C is incorrect because applying lotion can introduce contaminants to the lesion. Choice D is incorrect because covering the lesion with a dry gauze can lead to adherence of the gauze to the wound, causing trauma upon removal and disrupting the healing process.

4. Based on this strip, what is the interpretation of this rhythm?

• A. Atrial fibrillation.
• B. Ventricular tachycardia.
• C. Normal sinus rhythm.
• D. Second-degree heart block.

Correct answer: C

Rationale: The correct answer is C, Normal sinus rhythm. Normal sinus rhythm is characterized by a regular rhythm, normal P waves, and a consistent PR interval. In this context, the strip likely shows a normal ECG pattern with these characteristics, indicating a healthy heart rhythm. Choices A, B, and D are incorrect. Atrial fibrillation would show an irregularly irregular rhythm with no discernible P waves. Ventricular tachycardia would display wide QRS complexes and a fast heart rate. Second-degree heart block would exhibit intermittent dropped QRS complexes.

5. Fluids are restricted to 1500 ml/day for a male client with AKI. He is frustrated and complaining of constant thirst, and the nurse discovers that the family is providing the client with additional fluids. What intervention should the nurse implement?

• A. Remove all sources of liquids from the client's room
• B. Allow family to give the client a measured amount of ice chips
• C. Restrict family visiting until the client's condition is stable
• D. Provide the client with oral swabs to moisten his mouth

Correct answer: D

Rationale: In this scenario, the nurse should provide the client with oral swabs to moisten his mouth. This intervention helps alleviate the client's thirst without increasing fluid intake, which is essential in managing AKI. Removing all sources of liquids from the client's room (Choice A) may not address the underlying issue of thirst and could lead to increased frustration. Allowing the family to give the client ice chips (Choice B) would add to the client's fluid intake, contradicting the restriction. Restricting family visiting (Choice C) is not necessary and does not directly address the client's thirst.

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