Nursing Elites

1. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?

• A. Potassium 4.2 mEq/L
• B. Glucose 250 mg/dL
• C. Bicarbonate 20 mEq/L
• D. Sodium 135 mEq/L

Correct answer: B

Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.

2. What is the best way to monitor fluid balance in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Monitor blood pressure
• D. Check for edema

Correct answer: A

Rationale: Corrected Rationale: Daily weight monitoring is the most accurate way to assess fluid balance in patients receiving diuretics. Monitoring daily weight allows healthcare providers to track changes in fluid status more precisely. While monitoring intake and output (choice B) is essential, it may not provide a comprehensive picture of overall fluid balance. Monitoring blood pressure (choice C) is important but may not directly reflect fluid balance. Checking for edema (choice D) is useful but may not be as sensitive as daily weight monitoring in assessing fluid balance.

3. Which lab value should be monitored for a patient on warfarin therapy?

• A. Monitor INR
• B. Monitor potassium levels
• C. Monitor platelet count
• D. Monitor sodium levels

Correct answer: A

Rationale: The correct answer is to monitor INR for a patient on warfarin therapy. INR monitoring is crucial as it helps assess the therapeutic effectiveness and safety of warfarin. INR stands for International Normalized Ratio, and it measures the blood's ability to clot. Monitoring potassium levels (Choice B) is not specific to warfarin therapy. Monitoring platelet count (Choice C) is important but not the primary lab value for assessing warfarin therapy. Monitoring sodium levels (Choice D) is not directly related to warfarin therapy.

4. A nurse is planning care for a client who is experiencing acute mania. What intervention should the nurse include?

• A. Encourage the client to take frequent rest periods.
• B. Withdraw TV privileges if the client does not attend group therapy.
• C. Place the client in seclusion during periods of anxiety.
• D. Encourage the client to spend time in the day room.

Correct answer: A

Rationale: The correct answer is A: Encourage the client to take frequent rest periods. During acute mania, individuals often experience high levels of energy, decreased need for sleep, and increased activity levels. Encouraging the client to take frequent rest periods can help prevent exhaustion and promote better self-regulation. Choice B is incorrect because withdrawing TV privileges may not be directly related to managing acute mania. Choice C is incorrect as placing the client in seclusion can exacerbate feelings of anxiety and agitation. Choice D is incorrect as spending time in the day room may not address the need for rest and relaxation that is crucial during acute mania.

5. A nurse is caring for a client who is 36 weeks gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Proteinuria of 1+.
• B. Blood pressure 120/80 mm Hg.
• C. Respiratory rate of 18/min.
• D. Nonpitting ankle edema.

Correct answer: D

Rationale: Nonpitting ankle edema is a concerning sign of worsening preeclampsia due to fluid retention and should be reported immediately. Proteinuria of 1+ is a common finding in preeclampsia. A blood pressure of 120/80 mm Hg is within normal limits. A respiratory rate of 18/min is also within normal range. Therefore, choices A, B, and C are not as urgent as nonpitting ankle edema in this scenario.

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