Nursing Elites

1. A nurse is assessing a client who has diabetic ketoacidosis (DKA). Which of the following laboratory findings should the nurse expect?

• A. Blood glucose 120 mg/dL
• B. pH 7.32
• C. HCO3 25 mEq/L
• D. PaCO2 48 mm Hg

Correct answer: B

Rationale: The correct answer is B. A pH of 7.32 indicates metabolic acidosis, which is a hallmark of diabetic ketoacidosis (DKA). In DKA, blood glucose levels are typically elevated, bicarbonate levels are often low, and there is a compensatory respiratory response leading to a decrease in PaCO2. Option A is incorrect because a blood glucose level of 120 mg/dL is within the normal range and not indicative of DKA. Option C is incorrect because an HCO3 level of 25 mEq/L is not typically seen in DKA where bicarbonate levels are usually lower. Option D is incorrect because a PaCO2 of 48 mm Hg would not be expected in DKA; it would typically be lower due to compensatory respiratory alkalosis.

2. A community health nurse is teaching a group of clients about first aid for wounds. Which client statement indicates understanding?

• A. Remove blood-saturated dressings
• B. Apply clean dressings over the saturated ones and hold pressure
• C. Elevate the wound above heart level
• D. Leave the wound open to air

Correct answer: B

Rationale: The correct answer is B. Applying clean dressings over blood-saturated ones and holding pressure helps to control bleeding and prevent tissue disruption. Removing blood-saturated dressings can cause further damage by disrupting the forming clot. Elevating the wound above heart level is beneficial to reduce swelling, but it is not the best immediate action for a blood-saturated dressing. Leaving the wound open to air can increase the risk of infection and slow down the healing process.

3. When teaching a client about the use of trazodone, what should be included?

• A. It can cause sedation
• B. It is a stimulant
• C. It has no side effects
• D. It should be taken with food

Correct answer: A

Rationale: The correct answer is A. Trazodone can cause sedation, so clients should be cautioned about activities requiring alertness, like driving. Choice B is incorrect because trazodone is not a stimulant; it is actually a sedating antidepressant. Choice C is incorrect as all medications have potential side effects. Choice D is not specifically indicated for trazodone; the client should follow the prescribing healthcare provider's instructions regarding food intake.

4. A charge nurse discovers that a nurse did not notify the provider that a client's condition had changed. The charge nurse should identify that the nurse is accountable for which of the following torts?

• A. Assault
• B. Battery
• C. Negligence
• D. False imprisonment

Correct answer: C

Rationale: The correct answer is C: Negligence. Negligence refers to the failure to take reasonable care or fulfill a duty, which can cause harm to others. In this scenario, the nurse's failure to notify the provider of a change in the client's condition constitutes negligence as it breaches the standard of care expected in healthcare practice. Choice A, Assault, involves the threat of harmful or offensive contact, which is not applicable in this situation. Choice B, Battery, refers to the intentional harmful or offensive touching of another person without their consent, which is also not relevant here. Choice D, False imprisonment, involves the intentional confinement or restraint of an individual against their will, which is not the issue described in the scenario. Therefore, the most appropriate tort in this case is negligence.

5. While providing education about the use of lorazepam, which of the following should be included?

• A. It can cause dependency
• B. It can be taken with alcohol
• C. It has no side effects
• D. It is a stimulant

Correct answer: A

Rationale: The correct answer is A: 'It can cause dependency.' Lorazepam is a benzodiazepine known to cause dependency, so it is crucial for clients to be informed about this potential risk. Choice B is incorrect as combining lorazepam with alcohol can lead to increased sedation and other adverse effects. Choice C is incorrect because lorazepam, like any medication, can have side effects such as drowsiness, dizziness, or confusion. Choice D is also incorrect as lorazepam is a sedative-hypnotic medication, not a stimulant.

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