Nursing Elites

1. The nurse and an unlicensed nursing assistant are caring for a group of clients. Which nursing intervention should the nurse perform?

• A. Measure the client's output from the indwelling catheter.
• B. Record the client's intake and output on the I & O sheet.
• C. Instruct the client on appropriate fluid restrictions.
• D. Provide water for a client diagnosed with diabetes insipidus.

Correct answer: C

Rationale: Instructing the client on appropriate fluid restrictions is a nursing intervention that requires professional judgment and should be performed by the nurse. In this scenario, the nurse should provide education regarding fluid restrictions based on the client's individual needs. Measuring the client's output from the indwelling catheter (choice A) and recording intake and output (choice B) can be tasks delegated to the unlicensed nursing assistant. Providing water for a client diagnosed with diabetes insipidus (choice D) is not appropriate as these clients often require careful fluid management to prevent complications.

2. A client with DM demonstrates acute anxiety when first admitted for the treatment of hyperglycemia. The most appropriate intervention to decrease the client's anxiety would be to:

• A. Administer a sedative
• B. Make sure the client knows all the correct medical terms to understand what is happening.
• C. Ignore the signs and symptoms of anxiety so that they will soon disappear.
• D. Convey empathy, trust, and respect toward the client.

Correct answer: D

Rationale: Conveying empathy, trust, and respect can help reduce the client's anxiety and improve their overall experience during treatment. This approach creates a supportive environment and fosters a sense of safety and understanding for the client. Administering a sedative (Choice A) should not be the initial intervention for anxiety, as it does not address the underlying emotional needs of the client. Making sure the client knows all the correct medical terms (Choice B) may increase anxiety by overwhelming the client with technical information. Ignoring signs and symptoms of anxiety (Choice C) can lead to worsening distress and potential complications in the client's care.

3. A client newly diagnosed with DM asks a nurse why it is necessary to monitor blood glucose levels so often. The nurse's best response would be:

• A. It helps to adjust insulin doses more precisely.
• B. It helps to prevent complications of diabetes.
• C. It helps to identify the best diet for you.
• D. It helps to reduce the need for medications.

Correct answer: B

Rationale: Monitoring blood glucose levels frequently is crucial for preventing complications in diabetes. By keeping a close eye on blood glucose levels, healthcare providers can intervene in a timely manner if levels are out of range, thus reducing the risk of long-term complications such as nerve damage, kidney disease, and vision problems. Choices A, C, and D are incorrect because while monitoring blood glucose levels may indirectly contribute to adjusting insulin doses, identifying the best diet, and reducing the need for medications, the primary purpose is to prevent complications through timely interventions.

4. Which of the following actions could be considered a breach of patient confidentiality?

• A. Discussing patient information with other healthcare providers in a private setting.
• B. Sharing patient information with family members without the patient's consent.
• C. Discussing patient information in public areas where others may overhear.
• D. Sharing patient information in a private, secure setting with other healthcare providers involved in the patient's care.

Correct answer: C

Rationale: Discussing patient information in public areas where others may overhear is considered a breach of patient confidentiality because it compromises the privacy and confidentiality of the patient's health information. Choices A and D are not breaches of confidentiality as discussing patient information with other healthcare providers in a private setting or in a private, secure setting with those involved in the patient's care is appropriate. Choice B is also incorrect as sharing patient information with family members without the patient's consent could potentially be a breach of privacy but is not the best answer in this context.

5. A healthcare professional is monitoring a client newly diagnosed with DM for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if blood glucose levels are not adequately managed?

• A. Polyuria
• B. Diaphoresis
• C. Pedal edema
• D. Proteinuria

Correct answer: D

Rationale: Proteinuria is the correct answer because it indicates kidney damage, which is a common complication of uncontrolled diabetes. Elevated blood glucose levels over time can damage the kidneys, leading to proteinuria. Polyuria (excessive urination) is a symptom of diabetes but does not specifically indicate a risk for chronic complications. Diaphoresis (excessive sweating) and pedal edema (swelling of the lower limbs) are not direct indicators of chronic complications related to uncontrolled diabetes.

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