Nursing Elites

1. A client with type 2 diabetes mellitus arrives at the clinic reporting episodes of weakness and palpitations. Which finding should the nurse identify may indicate an emerging situation?

• A. History of hypertension
• B. Fingertips feel numb
• C. Reduced deep tendon reflexes
• D. Elevated fasting blood glucose level

Correct answer: B

Rationale: Numb fingertips may suggest neuropathy, a common complication of diabetes that may indicate a worsening condition. Episodes of weakness and palpitations, combined with neuropathy symptoms, could also suggest hypoglycemia or poor glycemic control, requiring further investigation. The other choices are less likely to be directly related to the client's current symptoms. While a history of hypertension is a common comorbidity in clients with diabetes, it may not directly explain the reported weakness and palpitations. Reduced deep tendon reflexes are more indicative of certain neurological conditions rather than acute emerging situations related to the client's current symptoms. An elevated fasting blood glucose level is expected in a client with type 2 diabetes and may not be the primary indicator of an emerging situation in this context.

2. A client receiving chemotherapy for cancer treatment is experiencing nausea and vomiting. What is the nurse's best intervention to manage these symptoms?

• A. Offer frequent, small meals
• B. Administer antiemetics before meals
• C. Encourage the client to eat a high-fat diet
• D. Provide the client with cold, carbonated beverages

Correct answer: B

Rationale: Administering antiemetics before meals is the best intervention to manage nausea and vomiting in clients receiving chemotherapy. This proactive approach helps control symptoms by preventing nausea from occurring, rather than waiting to treat it once symptoms have already started. Offering frequent, small meals (choice A) may worsen symptoms in some cases due to increased stomach activity. Encouraging a high-fat diet (choice C) can be difficult for nauseated clients and may not alleviate symptoms. Providing cold, carbonated beverages (choice D) could exacerbate nausea further due to the temperature and carbonation.

3. When asking an unlicensed assistive personnel (UAP) to assist a 69-year-old surgical client to ambulate for the first time, which statement by the nurse is appropriate?

• A. Have the client sit on the side of the bed for at least 2 minutes before helping him stand.
• B. If the client is dizzy on standing, ask him to take some deep breaths.
• C. Assist the client to the bathroom at least twice on this shift.
• D. After you assist him to the chair, let me know how he feels.

Correct answer: A

Rationale: The correct answer is A. Allowing the client to sit on the side of the bed before standing helps prevent dizziness and falls, especially during their first ambulation post-surgery. Choice B is incorrect because asking the client to take deep breaths when feeling dizzy may not address the underlying cause of the dizziness. Choice C is incorrect as it is unrelated to the task of assisting the client to ambulate for the first time. Choice D is incorrect because knowing how the client feels after sitting in the chair does not address the important step of assisting the client to stand up for the first time.

4. An elderly client reports new-onset confusion, nausea, dysuria, and urgency. What action should the nurse take first?

• A. Initiate intravenous fluids
• B. Obtain a clean-catch midstream urine specimen
• C. Administer antibiotics
• D. Start a Foley catheter to obtain a sterile sample

Correct answer: B

Rationale: The correct first action for the nurse to take in this scenario is to obtain a clean-catch midstream urine specimen. The client's symptoms of confusion, nausea, dysuria, and urgency are suggestive of a urinary tract infection (UTI). To confirm the diagnosis and identify the causative organism, a urine specimen should be collected before initiating any treatment. Initiating intravenous fluids (Choice A) may be necessary later based on the client's condition but is not the initial priority. Administering antibiotics (Choice C) should be done after confirming the diagnosis through urine culture. Starting a Foley catheter (Choice D) to obtain a sterile sample is more invasive and should not be the first step in the assessment and management of a suspected UTI.

5. A client with deep vein thrombosis (DVT) is prescribed anticoagulants. What should the nurse monitor closely?

• A. Monitor for signs of bleeding, such as bruising.
• B. Monitor the client’s vital signs every hour.
• C. Monitor for pain in the affected limb.
• D. Assess for signs of pulmonary embolism, such as sudden shortness of breath.

Correct answer: D

Rationale: In clients with DVT, assessing for pulmonary embolism is crucial as a clot in the lungs can be life-threatening. Sudden shortness of breath or chest pain are key signs of a pulmonary embolism. While monitoring for signs of bleeding is important due to anticoagulant therapy, the immediate concern is detecting a potential pulmonary embolism. Monitoring vital signs and pain in the affected limb are relevant aspects of care but are not as urgent as assessing for pulmonary embolism in this scenario.

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