Nursing Elites

1. What do crackles heard on lung auscultation indicate?

• A. Cyanosis.
• B. Bronchospasm.
• C. Airway narrowing.
• D. Fluid-filled alveoli.

Correct answer: D

Rationale: Crackles heard on lung auscultation are caused by the popping open of small airways that are filled with fluid. This is commonly associated with conditions such as pulmonary edema, pneumonia, or heart failure. Cyanosis (Choice A) is a bluish discoloration of the skin and mucous membranes due to low oxygen levels in the blood, not directly related to crackles. Bronchospasm (Choice B) refers to the constriction of the airway smooth muscle, causing difficulty in breathing but does not typically produce crackles. Airway narrowing (Choice C) can lead to wheezing but is not directly linked to crackles heard on auscultation.

2. Assessment of the diabetic client for common complications should include examination of the:

• A. Abdomen.
• B. Lymph glands.
• C. Pharynx.
• D. Eyes.

Correct answer: D

Rationale: The correct answer is D: Eyes. Diabetic clients are at high risk of developing complications such as diabetic retinopathy, making regular eye examinations crucial. Assessing the eyes helps in early detection and management of diabetic eye diseases. Choices A, B, and C are incorrect because while they may be relevant in certain assessments, they are not commonly associated with complications specific to diabetes. Examination of the abdomen, lymph glands, and pharynx are not typically part of routine assessments for common complications in diabetic clients.

3. What is the most common symptom of hypoglycemia that the nurse should teach the diabetic client to recognize?

• A. Nervousness
• B. Anorexia
• C. Kussmaul's respirations
• D. Bradycardia

Correct answer: A

Rationale: Nervousness is the most common symptom of hypoglycemia. It is often accompanied by other signs such as weakness, perspiration, confusion, and palpitations. Anorexia (lack of appetite) is not a typical symptom of hypoglycemia; it is more commonly associated with hyperglycemia. Kussmaul's respirations are a deep and labored breathing pattern seen in diabetic ketoacidosis, not hypoglycemia. Bradycardia (slow heart rate) is not a typical symptom of hypoglycemia; tachycardia (fast heart rate) is more commonly associated with hypoglycemia due to the release of catecholamines in response to low blood sugar.

4. The nurse is caring for a patient who is receiving isotonic intravenous (IV) fluids at an infusion rate of 125 mL/hour. The nurse performs an assessment and notes a heart rate of 102 beats per minute, a blood pressure of 160/85 mm Hg, and crackles auscultated in both lungs. Which action will the nurse take?

• A. Decrease the IV fluid rate and notify the provider.
• B. Increase the IV fluid rate and notify the provider.
• C. Request an order for a colloidal IV solution.
• D. Request an order for a hypertonic IV solution.

Correct answer: A

Rationale: The patient is showing signs of fluid volume excess, indicated by crackles in both lungs, increased heart rate, and elevated blood pressure. To address this, the nurse should decrease the IV fluid rate and notify the provider. Increasing the IV fluid rate would worsen fluid overload. Requesting colloidal or hypertonic IV solutions would exacerbate the issue by pulling more fluids into the intravascular space, leading to further volume overload.

5. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action?

• A. Provide additional oral fluid intake
• B. Measure the client's intake and output
• C. Increase the flow of the bladder irrigation
• D. Administer a PRN dose of an antispasmodic agent

Correct answer: C

Rationale: The best initial nursing action when observing an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation post-TURP is to increase the flow of the bladder irrigation. This action helps prevent blood clots from obstructing the catheter, ensuring effective drainage and promoting client comfort. Providing additional oral fluid intake (Choice A) is important for overall hydration but may not directly address the issue of blood clots in the drainage tubing. Measuring the client's intake and output (Choice B) is a routine nursing assessment that may not directly address the immediate concern of blood clots obstructing the catheter. Administering a PRN dose of an antispasmodic agent (Choice D) is not the best initial action as it does not directly address the issue of blood clots in the drainage tubing.

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