Nursing Elites

1. A client with diabetes mellitus is being taught by a nurse about preventing long-term complications. Which of the following client statements indicates an understanding of the teaching?

• A. I will keep my blood glucose levels within the target range.
• B. I will check my feet daily for any open sores or wounds.
• C. I will consume foods that are high in fiber.
• D. I will monitor my blood pressure regularly.

Correct answer: B

Rationale: The correct answer is B because checking the feet daily for open sores or wounds is crucial in preventing complications like diabetic foot ulcers. While maintaining blood glucose levels within the target range (choice A) is important in managing diabetes, it does not specifically address long-term complications. Consuming foods high in fiber (choice C) is beneficial for glycemic control but does not directly relate to preventing long-term complications. Monitoring blood pressure regularly (choice D) is important in managing diabetes but is not as directly related to preventing long-term complications as checking for foot wounds.

2. A nurse is planning care for a client who is 1 day postoperative following a hypophysectomy for the removal of a pituitary tumor. Which of the following findings requires further assessment by the nurse?

• A. Glasgow Coma Scale score of 15
• B. Blood drainage on the initial dressing measuring 3 cm
• C. Report of dry mouth
• D. Urinary output greater than fluid intake

Correct answer: D

Rationale: The correct answer is D. Urinary output greater than fluid intake could indicate diabetes insipidus, a complication following hypophysectomy. Diabetes insipidus is characterized by excessive urination and extreme thirst due to inadequate levels of antidiuretic hormone (ADH). Options A, B, and C are all expected findings in the immediate postoperative period following a hypophysectomy. A Glasgow Coma Scale score of 15 indicates the highest level of consciousness, blood drainage on the initial dressing is a common finding after surgery, and dry mouth can be a side effect of anesthesia and surgical procedures.

3. A nurse is assessing a client who has a history of urinary incontinence. Which of the following findings should the nurse report to the provider?

• A. Urine output of 50 mL in 2 hours
• B. Presence of an indwelling urinary catheter
• C. Frequent urination at night
• D. Dark-colored urine

Correct answer: D

Rationale: The correct answer is D, dark-colored urine. Dark-colored urine can indicate various issues such as dehydration, liver problems, or blood in the urine, which could be concerning and require further evaluation by the provider. Choices A, B, and C are not necessarily findings that would need immediate reporting to the provider. A urine output of 50 mL in 2 hours might be low but could be influenced by various factors and might not always require immediate action. The presence of an indwelling urinary catheter is a known history and not a new finding. Frequent urination at night could be a symptom related to various conditions but may not be an urgent concern unless accompanied by other significant symptoms.

4. A client has a new prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime to prevent nausea.
• B. Take this medication with a full glass of milk.
• C. Notify your provider if you experience visual disturbances.
• D. Report any muscle pain to your provider.

Correct answer: C

Rationale: The correct answer is C: 'Notify your provider if you experience visual disturbances.' Visual disturbances can indicate digoxin toxicity, so it is essential for clients taking digoxin to report any changes in vision to their healthcare provider. Option A is incorrect because the timing of digoxin administration is crucial, usually in the morning. Option B is inaccurate because digoxin should not be taken with milk as it can affect its absorption. Option D is not directly associated with digoxin use and should not be the priority instruction for a client on this medication.

5. A nurse is caring for a client in labor who is receiving electronic fetal monitoring. The nurse notes early decelerations. Which of the following should the nurse expect?

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

Correct answer: D

Rationale: When a nurse notes early decelerations in electronic fetal monitoring, it indicates head compression, which is generally considered benign and not associated with fetal hypoxia, abruptio placentae, or post maturity. Early decelerations mirror the uterine contractions and are a normal response to fetal head compression during labor.

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