Nursing Elites

1. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?

• A. Tremors
• B. Urine retention
• C. Kussmaul respirations
• D. Bradypnea

Correct answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.

2. During tracheostomy care, what action should a healthcare professional take?

• A. Use clean technique to remove the inner cannula.
• B. Remove the outer cannula for cleaning.
• C. Soak the inner cannula in normal saline.
• D. Change tracheostomy ties if they are wet.

Correct answer: D

Rationale: Changing tracheostomy ties if they are wet is essential to prevent infection and maintain skin integrity. Wet ties can harbor bacteria, increasing the risk of skin breakdown and other complications. Regularly changing wet ties promotes cleanliness, reduces the likelihood of complications, and ensures optimal care for the client with a tracheostomy.

3. What is a true statement about caring for a client with a nasogastric (NG) tube?

• A. The NG tube should be flushed with 30 mL of water every 4 hours.
• B. The client should be positioned in a supine position.
• C. The NG tube should be advanced 5 cm if resistance is met.
• D. The client's nasal mucosa should be inspected daily.

Correct answer: A

Rationale: Flushing the NG tube with 30 mL of water every 4 hours is crucial to maintain its patency and prevent blockages. This routine ensures the tube stays clear and functional, enabling proper delivery of medications and nutrition to the client. Regular flushing also helps prevent residue buildup or clogs within the tube, reducing risks like aspiration or inaccurate medication dosing.

4. A healthcare professional is preparing to administer an intramuscular injection to a client. Which of the following actions should the healthcare professional take?

• A. Use a 1-inch needle.
• B. Stretch the skin at the injection site.
• C. Insert the needle at a 90-degree angle.
• D. Aspirate for blood return before injecting.

Correct answer: D

Rationale: Aspirating for blood return before injecting is a crucial step in administering intramuscular injections. This action ensures that the needle is not in a blood vessel, reducing the risk of injecting medication into a blood vessel, which can lead to potential complications. Choices A, B, and C are incorrect. Using a longer 1-inch needle is often necessary for intramuscular injections to reach the muscle tissue properly. Stretching the skin is not recommended as it can cause unnecessary pain and tissue damage. Inserting the needle at a 90-degree angle is the preferred method for intramuscular injections to ensure proper medication delivery.

5. A client has a new diagnosis of hypertension, and the nurse is teaching them about the DASH diet. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of sodium-rich foods.
• B. You should decrease your intake of potassium-rich foods.
• C. You should increase your intake of fruits and vegetables.
• D. You should decrease your intake of whole grains.

Correct answer: C

Rationale: The DASH diet, recommended for managing hypertension, emphasizes increasing the intake of fruits and vegetables. These food groups are rich in essential nutrients, fiber, and antioxidants, which can help lower blood pressure levels and promote overall cardiovascular health.

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