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 nurse is caring for a client who has schizophrenia. Which of the following assessment findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Poor problem-solving ability
• D. Preoccupation with somatic disturbances

Correct answer: C

Rationale: In clients with schizophrenia, poor problem-solving ability is a common assessment finding due to impaired cognitive function associated with the disorder. This impairment can manifest as difficulties in decision-making and problem-solving. Choice A, decreased level of consciousness, is not a typical finding in schizophrenia. Choice B, inability to identify common objects, is more indicative of conditions like dementia rather than schizophrenia. Choice D, preoccupation with somatic disturbances, is more characteristic of somatic symptom disorder rather than schizophrenia.

3. A healthcare professional is preparing to administer a dose of nitroglycerin. Which of the following should be assessed first?

• A. Blood pressure
• B. Heart rate
• C. Pain level
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is to assess blood pressure first before administering nitroglycerin. Nitroglycerin is a vasodilator that can cause a sudden drop in blood pressure, leading to adverse effects such as dizziness or fainting. Assessing blood pressure before administration helps determine if the patient's blood pressure is within the acceptable range for nitroglycerin administration. Heart rate, pain level, and respiratory rate are also important assessments, but blood pressure should take precedence due to the vasodilating effects of nitroglycerin.

4. A nurse is caring for a client who is in labor and receiving electronic fetal monitoring. The nurse is reviewing the monitor tracing and notes early decelerations. What should the nurse expect?

• A. Fetal hypoxia
• B. Abruptio placentae
• C. Post-maturity
• D. Head compression

Correct answer: D

Rationale: When early decelerations are noted on the fetal monitor tracing, it indicates fetal head compression, which is typically a benign finding associated with the progress of labor. Early decelerations mirror the uterine contractions and are often not a cause for concern as they are a normal response to fetal head compression during contractions. Choices A, B, and C are incorrect as they do not align with the expected outcome of early decelerations. Fetal hypoxia, abruptio placentae, and post-maturity would present with different patterns on the fetal monitor tracing and would require different interventions.

5. A healthcare professional is preparing to administer a dose of potassium chloride. Which of the following should the professional do?

• A. Administer it as a bolus
• B. Dilute the medication
• C. Give it rapidly
• D. Monitor respiratory rate

Correct answer: B

Rationale: Correct Answer: Dilute the medication. Potassium chloride should always be diluted before administration to avoid irritation and complications. Choice A is incorrect because administering it as a bolus can lead to adverse effects. Choice C is incorrect as giving it rapidly can be dangerous. Choice D is incorrect as monitoring the respiratory rate is not directly related to administering potassium chloride.

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