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. A nurse is providing discharge teaching to a client who has a new prescription for lisinopril. Which of the following client statements indicates an understanding of the teaching?

• A. I may experience a persistent cough while taking this medication.
• B. I should take this medication with food.
• C. I should increase my intake of potassium-rich foods.
• D. I should stop taking this medication if I develop a headache.

Correct answer: A

Rationale: The correct answer is A: 'I may experience a persistent cough while taking this medication.' Lisinopril is known to cause a persistent cough as a common side effect. This statement indicates that the client understands the potential side effect associated with the medication. Choice B is incorrect because lisinopril is typically taken on an empty stomach. Choice C is incorrect as increasing potassium-rich foods without healthcare provider guidance can lead to hyperkalemia. Choice D is incorrect because a headache is not a common reason to stop taking lisinopril.

3. A nurse is assessing a client who has myasthenia gravis. Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased muscle strength.
• C. Diarrhea.
• D. Decreased deep tendon reflexes.

Correct answer: D

Rationale: The correct answer is D: Decreased deep tendon reflexes. In myasthenia gravis, muscle weakness is a common manifestation, leading to decreased deep tendon reflexes. Bradycardia (choice A) is not typically associated with myasthenia gravis. Increased muscle strength (choice B) is unlikely as muscle weakness is a hallmark of this condition. Diarrhea (choice C) is not a typical finding in myasthenia gravis.

4. What is the best intervention for a patient experiencing hypoxia?

• A. Administer oxygen
• B. Reposition the patient
• C. Provide humidified air
• D. Provide chest physiotherapy

Correct answer: A

Rationale: The best intervention for a patient experiencing hypoxia is to administer oxygen. Oxygen therapy helps improve oxygenation levels in the blood, addressing the underlying cause of hypoxia. Repositioning the patient, providing humidified air, and chest physiotherapy may be beneficial in certain situations but are not the primary interventions for hypoxia. Administering oxygen is crucial to quickly alleviate hypoxia and support the patient's respiratory function.

5. A nurse is caring for a client who is receiving continuous enteral nutrition through a nasogastric tube. Which of the following actions should the nurse take?

• A. Administer the feeding using a large-bore syringe
• B. Check the placement of the tube every 8 hours
• C. Flush the tube with 5 mL of water every 6 hours
• D. Maintain the client in an upright position

Correct answer: B

Rationale: The correct action for the nurse to take is to check the placement of the nasogastric tube every 8 hours. This is crucial to ensure that the tube is correctly positioned in the stomach, reducing the risk of complications such as aspiration. Administering the feeding using a large-bore syringe (Choice A) is not recommended for enteral nutrition. Flushing the tube with water every 6 hours (Choice C) is not necessary for continuous enteral nutrition. Maintaining the client in an upright position (Choice D) is generally preferred to reduce the risk of aspiration, but it is not the most critical action compared to verifying tube placement.

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