Nursing Elites

1. The nurse is caring for a client following a craniotomy. Which finding should the nurse report immediately?

• A. Pupils equal and reactive to light.
• B. Sudden increase in urine output.
• C. Diminished breath sounds bilaterally.
• D. Increase in blood pressure by 20 mmHg.

Correct answer: C

Rationale: The correct answer is C, 'Diminished breath sounds bilaterally.' This finding should be reported immediately as it could indicate a serious complication such as increased intracranial pressure or respiratory compromise. In a post-craniotomy client, changes in breath sounds may be a sign of developing issues that need prompt intervention. Choices A, B, and D are not as critical in the immediate post-craniotomy period. Pupils equal and reactive to light are expected findings, a sudden increase in urine output may require monitoring but not immediate reporting, and a small increase in blood pressure may not be alarming unless it is significantly high or accompanied by other concerning signs.

2. A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?

• A. Monitor the site for further complications.
• B. Promptly remove the catheter from the radial artery.
• C. Elevate the client’s arm above the heart.
• D. Notify the healthcare provider and prepare for surgery.

Correct answer: B

Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.

3. A client with type 1 diabetes is admitted to the emergency room with abdominal pain, polyuria, and confusion. What should the nurse implement first?

• A. Administer intravenous insulin.
• B. Start an intravenous fluid bolus.
• C. Obtain a blood glucose level.
• D. Administer an antiemetic.

Correct answer: B

Rationale: In this scenario, the nurse should first start an intravenous fluid bolus. This intervention is crucial in addressing severe dehydration associated with diabetic ketoacidosis, a life-threatening complication of type 1 diabetes. Administering intravenous insulin (Choice A) is important but should follow fluid resuscitation. Obtaining a blood glucose level (Choice C) is necessary but not as urgent as addressing the dehydration. Administering an antiemetic (Choice D) is not the priority in this situation.

4. A client with diabetes mellitus reports tingling in their feet. What is the nurse's best intervention?

• A. Advise the client to avoid wearing tight shoes.
• B. Refer the client to a podiatrist for foot care.
• C. Teach the client about blood sugar control and foot care.
• D. Administer insulin as prescribed.

Correct answer: C

Rationale: The correct intervention for a client with diabetes mellitus experiencing tingling in their feet is to teach the client about blood sugar control and foot care. This is essential because tingling in the feet can be a sign of neuropathy, a common complication of diabetes. Educating the client on maintaining proper blood sugar levels and foot care practices can help manage neuropathy symptoms and prevent complications like ulcers or infections. Advising the client to avoid tight shoes (Choice A) may help with comfort but does not address the underlying issue. Referring the client to a podiatrist (Choice B) is important for foot care but does not directly address blood sugar control. Administering insulin (Choice D) is not the priority for managing tingling in the feet related to neuropathy.

5. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6 hours are prescribed. What actions should the nurse include in this client's plan of care?

• A. Teach subcutaneous injection technique, site rotation, and insulin management
• B. Coordinate carbohydrate-controlled meals at consistent times and intervals
• C. Review with the client proper foot care and prevention of injury
• D. All of the above

Correct answer: D

Rationale: Effective diabetes management involves comprehensive care, including proper foot care, insulin administration technique, and maintaining carbohydrate consistency with meals. All of these interventions are critical in reducing hyperglycemic episodes and managing diabetes.

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