Nursing Elites

1. The nurse is providing care for a client with type 1 diabetes mellitus who is receiving NPH insulin. The nurse notices that the client's evening glucose levels are consistently above 260 mg/dl. What does this indicate?

• A. States that her feet are constantly cold and feel numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dl
• D. Reports nausea in the morning but still able to eat breakfast

Correct answer: C

Rationale: High evening glucose levels suggest that the current insulin dosage may be inadequate to control the client's blood sugar levels effectively. This indicates poor glycemic control and the need for a possible adjustment in the insulin regimen. Option A describes symptoms of peripheral neuropathy, which are not directly related to the elevated glucose levels but may be a long-term complication of diabetes. Option B describes a wound infection, which is not directly related to the client's high glucose levels. Option D mentions morning nausea, which could be due to various causes and is not directly related to the high evening glucose levels.

2. A client post-lobectomy is placed on mechanical ventilation. The nurse notices the client is fighting the ventilator. What should the nurse do first?

• A. Increase the sedation as prescribed.
• B. Manually ventilate the client using an ambu bag.
• C. Check the ventilator settings and alarms.
• D. Suction the client’s airway.

Correct answer: C

Rationale: The correct first action for the nurse to take when a client is fighting the ventilator is to check the ventilator settings and alarms. This step is crucial to ensure that the ventilator is functioning correctly and providing the necessary support to the client. Increasing sedation (Choice A) should only be considered after confirming that the ventilator settings are appropriate. While manually ventilating the client (Choice B) may be required in some cases, it is not the initial action to take. Suctioning the client's airway (Choice D) is not the priority in this situation, where the primary concern is addressing the client's struggle with the ventilator.

3. A client is recovering from a below-the-knee amputation (BKA). The client reports phantom limb pain. What should the nurse include in the client’s care plan to manage this type of pain?

• A. Apply heat to the residual limb.
• B. Administer prescribed analgesics.
• C. Elevate the residual limb.
• D. Perform range-of-motion exercises.

Correct answer: B

Rationale: Phantom limb pain is a type of pain that feels like it's coming from a body part that's no longer there. It is essential to understand that phantom limb pain is real and should be managed appropriately. Administering prescribed analgesics is the most effective way to address this discomfort. Applying heat, elevating the residual limb, and performing range-of-motion exercises are not effective in managing phantom limb pain since the pain originates from the brain expecting sensory input from the missing limb, rather than being related to physical factors that heat, elevation, or exercises can address.

4. The PN is caring for a laboring client whose last sterile vaginal examination revealed the cervix was 3 cm dilated, 50% effaced, and the presenting part was at 0 station. An hour later, the client tells the PN that she wants to go to the bathroom. Which action is most important for the PN to implement?

• A. Review the fetal heart rate and contraction pattern
• B. Check the perineum for an increase in bloody show
• C. Request a nurse to check the client's cervical dilation
• D. Palpate the client's bladder for distention

Correct answer: C

Rationale: The sudden urge to use the bathroom may indicate that labor is progressing quickly. Checking the cervical dilation will help determine if the client is in the transition phase of labor and if it is appropriate to allow her to get up. Reviewing the fetal heart rate and contraction pattern (Choice A) is important but not the most immediate action in this scenario. Checking the perineum for an increase in bloody show (Choice B) is relevant but not as crucial as assessing cervical dilation. Palpating the client's bladder for distention (Choice D) is not the priority when the client wants to go to the bathroom during labor.

5. The PN is reviewing care instructions with a client who has diabetic retinopathy and is experiencing glare around lights. What should the PN reinforce with the client?

• A. Cover eyes with moist, cool compresses to reduce glare
• B. Make adjustments to personal schedule to avoid driving at night
• C. Exert pressure on the inner canthus when tearing occurs
• D. Apply an eye shield at bedtime after instilling eye drops

Correct answer: B

Rationale: The correct answer is B. Avoiding driving at night is recommended for clients experiencing glare around lights due to diabetic retinopathy. This can help reduce the risk of accidents and visual discomfort. Making adjustments to the personal schedule to avoid nighttime driving is a practical approach to manage the glare. Choices A, C, and D are incorrect because covering eyes with compresses, exerting pressure on the inner canthus, or applying an eye shield are not effective strategies for managing glare associated with diabetic retinopathy.

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