Nursing Elites

1. A client with type 1 diabetes reports blurry vision. What is the most important assessment the nurse should perform?

• A. Assess the client’s most recent blood glucose levels.
• B. Check the client’s hemoglobin A1C level.
• C. Check the client’s blood pressure for signs of hypertension.
• D. Examine the client’s feet for signs of neuropathy.

Correct answer: A

Rationale: Blurry vision in clients with type 1 diabetes may indicate hyperglycemia, which requires prompt assessment of recent blood glucose levels to determine the cause and appropriate intervention. Checking the client’s hemoglobin A1C level (Choice B) is useful for assessing long-term glucose control, not for immediate management of blurry vision. Monitoring blood pressure (Choice C) is important in diabetes care but is not the most crucial assessment when blurry vision is reported. Examining the client’s feet for signs of neuropathy (Choice D) is important in diabetic foot care but is not the priority when dealing with blurry vision.

2. A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?

• A. Inspect the PICC insertion site for signs of infection.
• B. Observe the antecubital fossa for inflammation.
• C. Auscultate lung sounds for signs of respiratory distress.
• D. Check for signs of phlebitis or thrombosis along the catheter site.

Correct answer: B

Rationale: Observing the antecubital fossa for inflammation is crucial in clients with a PICC line and fever. Inflammation at the site can indicate infection or complications related to the PICC line. Auscultating lung sounds (choice C) is important but not the priority in this situation. Checking for phlebitis or thrombosis (choice D) is relevant but does not address the immediate concern of identifying infection or complications at the insertion site. Inspecting the PICC insertion site (choice A) is also important but observing the antecubital fossa provides a more direct assessment of potential issues with the PICC line.

3. A client with chronic kidney disease is prescribed erythropoietin. What lab value should the nurse monitor to evaluate the effectiveness of the therapy?

• A. White blood cell count.
• B. Hemoglobin level.
• C. Serum creatinine level.
• D. Platelet count.

Correct answer: B

Rationale: Erythropoietin therapy stimulates red blood cell production in clients with chronic kidney disease. Hemoglobin levels should be monitored to assess the effectiveness of the therapy and ensure the client is not developing anemia. Increased hemoglobin levels indicate successful treatment, whereas very high levels may suggest erythropoietin is overcorrecting the anemia. Monitoring the white blood cell count is not directly related to erythropoietin therapy for anemia. Serum creatinine level is used to assess kidney function rather than the effectiveness of erythropoietin therapy. Platelet count is not typically affected by erythropoietin therapy and is not a key indicator of its effectiveness.

4. The nurse is caring for a client with an acute myocardial infarction. Which symptom requires immediate intervention?

• A. Dizziness
• B. Shortness of breath
• C. Severe chest pain
• D. Nausea and vomiting

Correct answer: C

Rationale: Severe chest pain is the hallmark symptom of an acute myocardial infarction (heart attack) and requires immediate intervention to prevent further damage to the heart muscle. Chest pain in this context is often described as crushing, pressure, tightness, or heaviness. It can radiate to the arms, neck, jaw, back, or upper abdomen. Other symptoms like dizziness, shortness of breath, nausea, and vomiting may also occur in acute myocardial infarction, but chest pain is the most critical sign requiring prompt action as it signifies inadequate blood flow to the heart muscle. Shortness of breath may indicate heart failure, while nausea and vomiting can be associated with the sympathetic response to myocardial infarction. Dizziness could result from decreased cardiac output but is not as specific to myocardial infarction as severe chest pain.

5. The nurse has been teaching a client with congestive heart failure about proper nutrition. The selection of which lunch indicates the client has learned about sodium restriction?

• A. Cheese sandwich with a glass of 2% milk
• B. Sliced turkey sandwich and canned pineapple
• C. Cheeseburger and baked potato
• D. Mushroom pizza and ice cream

Correct answer: B

Rationale: The correct answer is B. A sliced turkey sandwich and canned pineapple are good choices for a client with congestive heart failure who is learning about sodium restriction. Turkey is generally lower in sodium compared to cheese, and canned fruits like pineapple typically have lower sodium content. Choices A, C, and D are less suitable as they contain higher levels of sodium, such as cheese, cheeseburger, baked potato, mushroom pizza, and ice cream, which are not ideal for a client needing to restrict sodium intake.

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