Nursing Elites

1. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which laboratory value is most concerning?

• A. Serum glucose of 300 mg/dL
• B. Blood pressure of 140/90 mmHg
• C. Serum osmolarity of 320 mOsm/kg
• D. Serum pH of 7.30

Correct answer: C

Rationale: In a client with hyperglycemic hyperosmolar syndrome (HHS), a serum osmolarity of 320 mOsm/kg is the most concerning laboratory value. This high osmolarity indicates severe dehydration, which can lead to serious complications. Elevated serum glucose levels (choice A) are expected in HHS but do not directly reflect dehydration. Blood pressure (choice B) and serum pH (choice D) are important parameters to monitor but are not the most concerning values in HHS compared to serum osmolarity.

2. Which nursing intervention has the highest priority for a multigravida who delivered twins and is at risk for postpartum hemorrhage?

• A. Maintain cold packs on the perineum for 24 hours.
• B. Assess the client's pain level frequently.
• C. Observe for appropriate interaction with the infants.
• D. Assess fundal tone and lochia flow.

Correct answer: D

Rationale: Assessing fundal tone and lochia flow is crucial in the early detection and prevention of postpartum hemorrhage. Fundal tone helps identify uterine atony, a common cause of postpartum hemorrhage, while monitoring lochia flow can indicate excessive bleeding. Cold packs on the perineum, although helpful for pain and swelling, are not the priority in this situation. Pain assessment and observing interactions with infants are important but secondary to assessing for signs of postpartum hemorrhage.

3. Which nursing intervention is most important when caring for a client with myasthenia gravis?

• A. Encourage the client to rest frequently.
• B. Administer medication 30 minutes before meals.
• C. Maintain a patent airway.
• D. Monitor for signs of respiratory infection.

Correct answer: C

Rationale: Maintaining a patent airway is crucial for clients with myasthenia gravis because muscle weakness can affect the muscles responsible for breathing, potentially leading to respiratory compromise. Encouraging rest, administering medication, and monitoring for respiratory infections are important aspects of care but do not take precedence over ensuring a patent airway for adequate oxygenation.

4. A client with gestational diabetes, at 39 weeks of gestation, is in the second stage of labor. After delivering the fetal head, the nurse recognizes that shoulder dystocia is occurring. What intervention should the nurse implement first?

• A. Prepare the client for an emergency cesarean birth
• B. Encourage the client to move to a hands-and-knees position
• C. Assist the client to sharply flex her thighs up against the abdomen
• D. Lower the head of the bed and apply suprapubic pressure

Correct answer: C

Rationale: In cases of shoulder dystocia, the priority intervention is to assist the client in sharply flexing her thighs up against the abdomen (McRoberts maneuver). This action helps to widen the pelvic outlet. Encouraging the client to move to a hands-and-knees position may also be beneficial in some cases but is not the first-line intervention. Preparing for an emergency cesarean birth and applying suprapubic pressure are not appropriate initial interventions for shoulder dystocia.

5. 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.

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