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. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago suddenly becomes restless and agitated.

• A. Increase the room temperature.
• B. Assess the oxygen saturation.
• C. Continue to monitor vital signs.
• D. Notify the rapid response team.

Correct answer: D

Rationale: In a burn patient with sudden restlessness and agitation, it is crucial to consider hypoxia or other critical conditions. As such, notifying the rapid response team is the most appropriate action to ensure prompt assessment and intervention. Increasing room temperature (Choice A) is not the priority in this scenario. While monitoring vital signs (Choice C) is important, the sudden change in behavior warrants immediate action. Assessing oxygen saturation (Choice B) is a step in the right direction, but involving the rapid response team ensures a comprehensive evaluation and timely management of the patient's condition.

3. What is the most critical initial intervention for a client who is actively seizing?

• A. Restrain the client to prevent injury
• B. Insert an oral airway
• C. Turn the client to the side
• D. Apply soft restraints to the wrists

Correct answer: C

Rationale: The most critical initial intervention for a client who is actively seizing is to turn the client to the side. This action helps maintain an open airway and prevents aspiration during a seizure. Restrain the client to prevent injury (Choice A) is incorrect because restraining a client during a seizure can lead to injury. Inserting an oral airway (Choice B) is not recommended as it can cause injury and is not necessary during an active seizure. Applying soft restraints to the wrists (Choice D) is also not recommended as it can lead to harm and does not address the immediate airway management needed during a seizure.

4. A young adult client, admitted to the emergency department following a motor vehicle collision, is transfused with 4 units of PRBCs. The client’s pretransfusion hematocrit is 17%. Which hematocrit value should the nurse expect the client to have after all PRBCs have been transfused?

• A. 23%
• B. 25%
• C. 27%
• D. 29%

Correct answer: D

Rationale: One unit of PRBCs typically raises the hematocrit by 3%. Since the client received 4 units, the hematocrit is expected to increase by approximately 12% (4 units x 3% per unit). Therefore, the nurse should expect the client's hematocrit to be 29% after all PRBCs have been transfused. Choices A, B, and C are incorrect as they do not account for the cumulative effect of multiple PRBC units on the hematocrit level.

5. 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.

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