Nursing Elites

1. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L, and blood glucose is 310 mg/dl. Which action should the nurse implement?

• A. Infuse sodium chloride 0.9% (normal saline)
• B. Prepare an emergency dose of glucagon
• C. Determine the last time the client ate
• D. Check urine for ketone bodies with a dipstick

Correct answer: A

Rationale: In DKA, restoring fluid balance with sodium chloride is a priority to address the dehydration and electrolyte imbalances present in this condition. Choice B, preparing an emergency dose of glucagon, is incorrect because DKA is characterized by insulin deficiency, not glucagon deficiency. Choice C, determining the last time the client ate, is not the immediate priority in managing DKA. Choice D, checking urine for ketone bodies with a dipstick, may help confirm the diagnosis of DKA but is not the most critical intervention at this time.

2. The nurse is assessing a client with left-sided heart failure. Which assessment finding requires immediate intervention?

• A. Jugular venous distention
• B. Shortness of breath
• C. Crackles in the lungs
• D. Peripheral edema

Correct answer: C

Rationale: In a client with left-sided heart failure, crackles in the lungs are a critical assessment finding that necessitates immediate intervention. Crackles indicate pulmonary congestion, a sign of worsening heart failure that requires prompt attention to prevent respiratory distress. Jugular venous distention, shortness of breath, and peripheral edema are also common in heart failure, but crackles specifically point to pulmonary involvement and the urgent need for intervention.

3. A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which intervention should the nurse implement first?

• A. Administer 50% dextrose IV push.
• B. Administer insulin as prescribed.
• C. Monitor the client's urine output.
• D. Obtain a blood glucose level.

Correct answer: A

Rationale: Administering 50% dextrose IV push is the first priority in treating a blood glucose level of 600 mg/dl in a client who is unresponsive due to hyperglycemia. This intervention is crucial to rapidly raise the client's blood glucose levels and address the emergency situation. Administering insulin (Choice B) would further lower the blood glucose level, worsening the client's condition. Monitoring urine output (Choice C) and obtaining a blood glucose level (Choice D) are important assessments but are secondary to the immediate need to address the high blood glucose levels causing the client's unresponsiveness.

4. During the infusion of a second unit of packed red blood cells, the client's temperature increases from 99 to 101.6 F. Which intervention should the nurse implement?

• A. Stop the transfusion and start a saline infusion.
• B. Administer antipyretics and continue the transfusion.
• C. Monitor the client’s vital signs every 15 minutes.
• D. Notify the healthcare provider and continue the transfusion.

Correct answer: A

Rationale: An increase in temperature during a transfusion may indicate a transfusion reaction, which can be serious. Stopping the transfusion and starting a saline infusion is the priority action to prevent further complications and address the potential adverse reaction. Administering antipyretics (choice B) may mask the symptoms of a transfusion reaction, delaying appropriate treatment. While monitoring vital signs (choice C) is important, stopping the transfusion takes precedence to prevent harm. Notifying the healthcare provider (choice D) is essential but should not delay the immediate intervention of stopping the transfusion and starting a saline infusion.

5. During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?

• A. Infection
• B. Hypoxia
• C. Bleeding
• D. Bronchospasm

Correct answer: A

Rationale: The correct answer is A: Infection. Improper suctioning techniques can introduce pathogens, increasing the risk of infection. Choice B, Hypoxia, is incorrect as it is more related to inadequate oxygen supply. Choice C, Bleeding, is not typically associated with suctioning a tracheostomy unless done too aggressively. Choice D, Bronchospasm, is not directly linked to suctioning but may occur due to other triggers in patients with sensitive airways.

Similar Questions