Nursing Elites

1. An older client with long-term type 2 diabetes Mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment would the nurse complete to determine if a patient with type 2 diabetes Mellitus (DM) is experiencing long-term complications?

• A. Signs of respiratory tract infection
• B. Sensation in feet and legs
• C. Skin condition of lower extremities
• D. Serum creatinine and blood urea nitrogen (BUN)

Correct answer: B

Rationale: Assessing sensation in the feet and legs is crucial for detecting diabetic neuropathy, a common long-term complication of diabetes. While signs of respiratory tract infection, skin condition of lower extremities, and serum creatinine and blood urea nitrogen levels are important assessments in diabetic care, they are not specific for detecting long-term complications like neuropathy.

2. Which of the following lab values would be most concerning in a patient receiving heparin therapy?

• A. Elevated hemoglobin levels.
• B. Low platelet count.
• C. High potassium levels.
• D. Low sodium levels.

Correct answer: B

Rationale: A low platelet count is most concerning in patients receiving heparin therapy due to the risk of heparin-induced thrombocytopenia. Heparin can sometimes cause a drop in platelet count, leading to a potentially serious condition where blood does not clot as it should. This can result in excessive bleeding or clot formation in blood vessels. Elevated hemoglobin levels, high potassium levels, and low sodium levels are not typically associated with heparin therapy and are less likely to cause immediate concerns or complications in this context.

3. In a client with heart failure presenting bilateral +4 edema of the right ankle extending up to midcalf while sitting with legs dependent, what is the priority goal?

• A. Decrease venous congestion.
• B. Maintain normal respirations.
• C. Maintain body temperature.
• D. Prevent injury to lower extremities.

Correct answer: A

Rationale: The priority goal in this scenario is to decrease venous congestion. By elevating the legs above the heart level, venous return is improved, reducing congestion in the lower extremities. This intervention helps decrease swelling and prevents complications such as impaired tissue perfusion. Maintaining normal respirations and body temperature are important aspects of care but are secondary to addressing the immediate issue of venous congestion. Preventing injury to lower extremities is also essential but takes precedence after managing the venous congestion to prevent further complications.

4. A client diagnosed with a history of asthma and bronchitis arrives at the clinic with shortness of breath, productive cough with thickened, tenacious mucus, and the inability to walk up a flight of stairs without experiencing breathlessness. Which action is most important for the nurses to instruct the client about self-care?

• A. Call the clinic if undesirable side effects of medications occur
• B. Avoid crowded enclosed areas to reduce pathogen exposure
• C. Increase the daily intake of oral fluids to liquefy secretions
• D. Teach anxiety reduction methods for feelings of suffocation

Correct answer: C

Rationale: Increasing the daily intake of oral fluids is crucial for clients with asthma and bronchitis as it helps to liquefy thickened mucus, making it easier to clear the airways and manage symptoms. This self-care measure can improve the client's ability to breathe more effectively. Choice A is not the most immediate concern when addressing thickened mucus and breathing difficulties. While avoiding crowded areas is beneficial to prevent respiratory infections, it is not directly related to managing thickened secretions. Teaching anxiety reduction methods is important for overall well-being, but it does not directly address the physiological issue of thickened mucus in the airways.

5. A young adult asks the nurse about the normal cholesterol level. The nurse tells the client that the total cholesterol level should be maintained at less than:

• A. 140 mg/dL
• B. 200 mg/dL
• C. 250 mg/dL
• D. 300 mg/dL

Correct answer: B

Rationale: The correct answer is B: 200 mg/dL. A normal cholesterol value ranges between 140 and 199 mg/dL. Total cholesterol levels should ideally be maintained at 200 mg/dL or less to reduce the risk of cardiovascular diseases. Choices A, C, and D are incorrect as they exceed the recommended normal range for total cholesterol levels and may increase the risk of developing heart-related issues.

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