Nursing Elites

1. The client with a new diagnosis of type 2 diabetes is being taught about diet management by the nurse. Which statement by the client indicates effective learning?

• A. I should not avoid all carbohydrates
• B. I can eat whatever I want as long as I take my medication
• C. I need to eat regular meals and snacks to maintain my blood sugar levels
• D. I will decrease my intake of sugary foods to prevent low blood sugar

Correct answer: C

Rationale: Choice C is the correct answer because eating regular meals and snacks is crucial for maintaining stable blood sugar levels in individuals with diabetes. This approach helps prevent spikes and drops in blood sugar, promoting better management of the condition. Choices A, B, and D are incorrect. Avoiding all carbohydrates is not recommended as they are a major energy source and can be part of a balanced diet; eating whatever one wants while relying solely on medication can lead to uncontrolled blood sugar levels and complications; decreasing sugary foods intake can actually contribute to high blood sugar levels rather than preventing low blood sugar.

2. Following an open reduction of the tibia, the nurse notes fresh bleeding on the client's cast. What intervention should the nurse implement?

• A. Assess the client's hemoglobin levels to determine if the client is in shock
• B. Call the surgeon and prepare to take the client back to the operating room
• C. Outline the area with ink and check it every 15 minutes to monitor for changes in bleeding
• D. No action is required as postoperative bleeding can be expected

Correct answer: C

Rationale: In this scenario, the correct intervention is to outline the area with ink and check it every 15 minutes to monitor for changes in bleeding. This approach helps in assessing the extent and progression of the bleeding. Option A is incorrect because assessing hemoglobin levels would not provide immediate information on the ongoing bleeding. Option B is premature without first monitoring the bleeding site. Option D is incorrect because although some postoperative bleeding can be expected, fresh bleeding on the cast warrants immediate monitoring and evaluation.

3. A client with a history of asthma is experiencing wheezing and shortness of breath. What is the priority nursing intervention?

• A. Administer a bronchodilator as prescribed
• B. Encourage the client to drink fluids
• C. Place the client in an upright position
• D. Assess the client's peak flow rate

Correct answer: A

Rationale: Administering a bronchodilator as prescribed is the priority nursing intervention for a client experiencing wheezing and shortness of breath due to asthma. Bronchodilators help relieve bronchoconstriction, allowing better airflow and improving breathing. Encouraging the client to drink fluids may be beneficial in certain situations, but it is not the priority when the client is in respiratory distress. Placing the client in an upright position, not supine, can facilitate easier breathing by allowing the chest to expand fully. While assessing the client's peak flow rate is important in asthma management, in this acute situation, the priority is to provide immediate relief by administering the bronchodilator.

4. A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?

• A. Compartment syndrome
• B. Deep vein thrombosis
• C. Wound infection
• D. All of the above

Correct answer: A

Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.

5. The nurse is in charge of a Nursing unit in a long-term care facility. Which task is best for the nurse to assign to an unlicensed assistive personnel (UAP) who is helping with the care of several clients?

• A. Measure the amount of a client's residual urine after voiding
• B. Cleanse the perineal area of a client with urinary incontinence
• C. Insert a straight catheter to obtain a urine specimen for culture
• D. Provide catheter care for a client with a suprapubic catheter

Correct answer: B

Rationale: The correct answer is B because cleaning the perineal area is a task within the scope of practice for unlicensed assistive personnel (UAPs) and is crucial for preventing infections. Choice A involves a more complex task that requires a healthcare provider's assessment. Choice C involves a sterile procedure that should be performed by licensed staff. Choice D involves specific care for a client with a catheter that exceeds the UAP's scope of practice.

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