Nursing Elites

1. What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?

• A. Impaired Skin Integrity
• B. Knowledge Deficit: New Diabetes Diagnosis
• C. Alteration in Nutrition: More than Body Requirements
• D. Fluid Volume Deficit

Correct answer: B

Rationale: The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans. Choices A and D aim to prevent issues that do not currently exist for the client. Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.

2. When dressing a severe burn to the right hand, it is important for the nurse to:

• A. Apply a wet-to-dry dressing for debridement
• B. Wrap each digit individually to prevent webbing
• C. Open blisters to allow drainage prior to dressing
• D. Allow the client to do as much of the dressing change as possible

Correct answer: B

Rationale: When dressing a severe burn to the hand, it is crucial to wrap each digit individually to prevent webbing, which can lead to contractures and impaired function. Applying a wet-to-dry dressing for debridement is not recommended for burn wounds as it can cause trauma to the wound bed during removal. Opening blisters can increase the risk of infection and delay healing. Allowing the client to perform the dressing change may not ensure proper care and can lead to complications.

3. One day postoperative, the client complains of dyspnea, and his respiratory rate (RR) is 35, slightly labored, and there are no breath sounds in the lower-right base. The nurse should suspect:

• A. cor pulmonale.
• B. atelectasis.
• C. pulmonary embolism.
• D. cardiac tamponade.

Correct answer: B

Rationale: The correct answer is atelectasis. The absence of breath sounds in the lower-right base is a key finding in atelectasis, which occurs when a portion of the lung collapses. The other symptoms such as dyspnea and increased respiratory rate could be present in various pulmonary conditions. Cor pulmonale is typically associated with chronic lung disease, pulmonary embolism presents with sudden onset dyspnea and chest pain, and cardiac tamponade manifests with Beck's triad of hypotension, distended neck veins, and muffled heart sounds.

4. Which of the following observations is most important when assessing a client's breathing?

• A. presence of breathing and pulse rate
• B. breathing pattern and adequacy of breathing
• C. presence of breathing and adequacy of breathing
• D. patient position and adequacy of breathing

Correct answer: C

Rationale: The correct answer is the presence of breathing and adequacy of breathing. It is crucial to ensure that the client is not only breathing but also breathing adequately. Choices A and D are incorrect as pulse rate and patient position are not the most critical observations when assessing a client's breathing. Pulse rate is more related to assessing circulation, and patient position is important but not as crucial as ensuring the client is breathing and breathing adequately. Choice B is partially correct as breathing pattern is important, but the most critical observation is the adequacy of breathing. Adequacy of breathing ensures that the client is receiving enough oxygen to support proper body function and is the key focus during breathing assessment.

5. Which of the following injuries, presented by a client entering the Emergency Department, is the highest priority?

• A. open leg fracture
• B. open head injury
• C. stab wound to the chest
• D. traumatic amputation of a thumb

Correct answer: C

Rationale: A stab wound to the chest is the highest priority injury. This type of injury can lead to lung collapse and mediastinal shift, potentially resulting in death if left untreated. Treating an obstructed airway or a chest wound takes precedence over addressing hemorrhage. The principle of ABC (airway, breathing, and circulation) guides care decisions in prioritizing life-threatening situations. An open leg fracture, open head injury, and traumatic amputation of a thumb, while serious, do not pose an immediate threat to life compared to a stab wound to the chest. An open leg fracture may lead to significant blood loss but is not immediately life-threatening. An open head injury requires assessment and intervention but does not impact airway, breathing, or circulation directly. Traumatic amputation of a thumb is a serious injury but can be managed after addressing more life-threatening conditions.

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