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. The client is admitted with a period of unobserved loss of consciousness and now has an EEG scheduled this morning. What should the nurse implement?

• A. Keep NPO and hold medication.
• B. Hold sedatives, but allow the client to have breakfast and give other medicines.
• C. Administer medications, but hold anticonvulsants.
• D. Give additional fluids and some caffeine prior to the test.

Correct answer: C

Rationale: Prior to an EEG, it is essential for the client to eat to prevent a drop in blood sugar levels. The nurse should hold sedatives but allow the client to have breakfast and administer other necessary medications. Holding sedatives is crucial to ensure accurate EEG results, while providing breakfast helps maintain stable blood sugar levels. Administering other medications, excluding sedatives, is important for the client's overall care. Choices A, C, and D are incorrect because keeping the client NPO and holding medications, administering medications but holding anticonvulsants, and giving additional fluids and caffeine are not appropriate actions before an EEG.

3. The schizophrenic client who is admitted to the hospital for possible bowel obstruction has an NG tube and complains of pain. What should the nurse do at this time?

• A. Decrease the stimuli and observe frequently
• B. Administer the PRN sedative
• C. Call the physician immediately
• D. Administer the PRN pain medication

Correct answer: D

Rationale: In this scenario, the nurse should administer the PRN (as needed) pain medication to address the schizophrenic client's complaint of pain. It is essential to provide relief and comfort to the client experiencing pain. Option A, decreasing stimuli and observing frequently, may not address the underlying cause of pain and delay relief. Option B, administering a sedative, does not target the pain but may mask symptoms. Option C, calling the physician immediately, while important in some situations, is not the most immediate action needed to alleviate the client's pain. Therefore, the most appropriate action at this time is to administer the PRN pain medication to help alleviate the client's discomfort.

4. Teaching about the need to avoid foods high in potassium is most important for which client?

• A. a client receiving diuretic therapy
• B. a client with an ileostomy
• C. a client with metabolic alkalosis
• D. a client with renal disease

Correct answer: D

Rationale: Clients with renal disease are predisposed to hyperkalemia and should avoid foods high in potassium. High potassium levels can further burden the kidneys and worsen the condition. Choices A, B, and C are incorrect because clients receiving diuretic therapy, with an ileostomy, or with metabolic alkalosis are at risk for hypokalemia, which is low potassium levels. Therefore, these clients should actually be encouraged to eat foods high in potassium to maintain adequate levels and prevent complications associated with hypokalemia.

5. The nurse observes a nursing assistant performing AM care for a client with a new leg cast. Which action by the assistant will the nurse intervene?

• A. Lifting the affected leg with the palms of the hands
• B. Covering the affected leg with a blanket to avoid chills
• C. Placing plastic over the groin prior to bathing
• D. Elevating the casted leg on two pillows

Correct answer: B

Rationale: The correct answer is to intervene when the assistant covers the affected leg with a blanket to avoid chills. A new cast should not be covered to allow the heat from the cast to evaporate, preventing complications. Lifting the affected leg with the palms of the hands is appropriate for proper handling. Placing plastic over the groin prior to bathing is a standard practice to protect the client's privacy and maintain hygiene. Elevating the casted leg on two pillows helps reduce swelling and promote circulation, making it a suitable action.

Similar Questions