Nursing Elites

1. Following routine diagnostic tests, a client who is symptom-free is diagnosed with Paget's disease. Client teaching should be directed toward what important goal for this client?

• A. Maintain adequate cardiac output.
• B. Promote adequate tissue perfusion.
• C. Promote rest and sleep.
• D. Reduce the risk for injury.

Correct answer: D

Rationale: In Paget's disease, bone remodeling is affected, leading to increased risk for fractures. Therefore, the primary goal of client teaching should focus on reducing the risk for injury. Choices A and B are not directly related to the primary concern of Paget's disease, which is bone fractures. Choice C, promoting rest and sleep, is important for overall health but is not the priority when considering the specific risks associated with Paget's disease.

2. A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which intervention should the nurse implement first?

• A. Obtain a blood glucose level.
• B. Administer an anticoagulant as prescribed.
• C. Perform a neurological assessment.
• D. Administer aspirin as prescribed.

Correct answer: C

Rationale: Performing a neurological assessment is the priority in this situation as it helps in evaluating the cause of the new onset of confusion in a client with atrial fibrillation. This assessment will provide crucial information about the client's neurological status, which can guide further interventions. Obtaining a blood glucose level (Choice A) is important but should not be the first step when dealing with a new onset of confusion. Administering an anticoagulant (Choice B) or aspirin (Choice D) may be necessary depending on the underlying cause, but assessing the neurological status comes first to determine the appropriate course of action.

3. 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.

4. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?

• A. Elevate the head of the bed.
• B. Administer oxygen therapy as prescribed.
• C. Assess the client's oxygen saturation.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: C

Rationale: Assessing the client's oxygen saturation is the first priority in managing a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. Monitoring oxygen saturation levels helps in determining the effectiveness of the oxygen therapy and if adjustments are needed. Elevating the head of the bed can help with breathing but is not the first priority. Administering oxygen therapy as prescribed is important, but assessing the current oxygen saturation comes before administering more oxygen. Obtaining an arterial blood gas (ABG) sample may provide valuable information, but it is not the initial intervention needed in this situation.

5. A client who is post-op day 1 after abdominal surgery reports pain at the incision site. The nurse notes the presence of a small amount of serosanguineous drainage. What is the most appropriate nursing action?

• A. Apply a sterile dressing to the incision.
• B. Reinforce the dressing and document the findings.
• C. Remove the dressing and assess the incision site.
• D. Notify the healthcare provider.

Correct answer: B

Rationale: The correct answer is to reinforce the dressing and document the findings. It is important to monitor the incision site closely after surgery, especially when there is a small amount of serosanguineous drainage. Reinforcing the dressing helps maintain cleanliness and pressure on the wound. Documenting the findings is crucial for tracking the client's progress and alerting healthcare providers if necessary. Applying a sterile dressing (Choice A) may not be needed if the current dressing is intact. Removing the dressing (Choice C) can increase the risk of contamination. Notifying the healthcare provider (Choice D) is not the first step for minor drainage on post-op day 1.

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