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. An adult female client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. After starting medication therapy, the nurse notices the client has more energy, is giving away her belongings, and has an elevated mood. Which intervention is best for the nurse to implement?

• A. Support the client by telling her what wonderful progress she is making.
• B. Ask the client if she has had any recent thoughts of harming herself.
• C. Reassure the client that the antidepressant drugs are apparently effective.
• D. Tell the client to keep her belongings because she will need them at discharge.

Correct answer: B

Rationale: When a client with major depressive disorder shows signs of increased energy, giving away belongings, and an elevated mood, it could indicate a shift towards suicidal behavior. Therefore, the best intervention for the nurse is to ask the client if she has had any recent thoughts of harming herself. This is crucial to assess the client's risk for suicide and provide necessary interventions. Choices A, C, and D are incorrect because they do not address the potential risk of harm to the client and do not prioritize the immediate assessment required in this situation.

3. A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?

• A. Collect a clean-catch specimen
• B. Administer prescribed antibiotics
• C. Perform a bladder scan
• D. Increase the client's fluid intake

Correct answer: A

Rationale: The correct action for the nurse to implement next is to collect a clean-catch specimen. This is essential to diagnose the cause of the client's symptoms accurately before initiating any treatment. Administering antibiotics (Choice B) without confirming the diagnosis through a specimen collection can be inappropriate and potentially harmful. Performing a bladder scan (Choice C) may not provide the necessary information to identify the specific cause of the symptoms. Increasing the client's fluid intake (Choice D) is a general recommendation and may not address the underlying issue causing the symptoms.

4. A client with a history of angina pectoris is prescribed sublingual nitroglycerin. Which client statement indicates that further teaching is needed?

• A. ‘I should take the nitroglycerin with a full glass of water.’
• B. ‘I should take the nitroglycerin as soon as I feel chest pain.’
• C. ‘I can take up to three doses of nitroglycerin if needed.’
• D. ‘I should call 911 if my chest pain does not improve after the first dose.’

Correct answer: A

Rationale: The correct answer is A. Sublingual nitroglycerin should not be taken with water, as it needs to dissolve under the tongue to be effective. Option B is correct as the client should take nitroglycerin as soon as they feel chest pain. Option C is correct as up to three doses can be taken if needed. Option D is correct as the client should seek emergency help if chest pain does not improve after the first dose.

5. A 3-year-old boy with a congenital heart defect is brought to the clinic by his mother. During the assessment, the mother asks the nurse why her child is at the 5th percentile for growth. What response is best for the nurse to provide?

• A. Does your child seem mentally slower than his peers also?
• B. His smaller size is probably due to the heart disease
• C. Haven't you been feeding him according to recommended daily allowances for children?
• D. You should not worry about the growth tables. They are only averages for children

Correct answer: B

Rationale: Heart disease can affect growth, leading to smaller size in children.

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