Nursing Elites

1. What action should the nurse take for a patient admitted with diabetic ketoacidosis exhibiting rapid, deep respirations?

• A. Administer the prescribed PRN lorazepam (Ativan).
• B. Start the prescribed PRN oxygen at 2 to 4 L/min.
• C. Administer the prescribed normal saline bolus and insulin.
• D. Encourage the patient to practice guided imagery for relaxation.

Correct answer: C

Rationale: The correct action for a patient with diabetic ketoacidosis and rapid, deep (Kussmaul) respirations is to administer a normal saline bolus and insulin. The rapid, deep respirations indicate a metabolic acidosis, which requires correction with a saline bolus to prevent hypovolemia and insulin to facilitate glucose re-entry into cells. Oxygen therapy is not necessary since the increased respiratory rate is compensatory and not due to hypoxemia. Encouraging relaxation techniques or administering lorazepam are inappropriate as they can worsen the acidosis by suppressing the compensatory respiratory effort.

2. A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of the prescribed 4 mg. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states her pain has subsided. What is the legal status of the nurse?

• A. The nurse is guilty of negligence and will be sued.
• B. The client would not be able to prove malpractice in court.
• C. The nurse is protected by the Good Samaritan Act.
• D. The healthcare provider should have given the morphine sulfate dose.

Correct answer: B

Rationale: The correct answer is B because, in this scenario, the client would not be able to prove malpractice in court. Despite the nurse administering a higher dose of morphine than prescribed, the client's respiratory rate, oxygen saturation, and pain relief indicate that no harm resulted from the error. Therefore, the client would not have legal grounds to pursue a malpractice case against the nurse.

3. A client with a diagnosis of schizophrenia is being treated with risperidone (Risperdal). Which finding should the nurse report to the healthcare provider immediately?

• A. Weight gain.
• B. Dry mouth.
• C. Muscle rigidity.
• D. Drowsiness.

Correct answer: C

Rationale: Muscle rigidity is a crucial finding to report immediately as it can indicate neuroleptic malignant syndrome (NMS), a rare but potentially life-threatening reaction to antipsychotic medications. NMS is characterized by muscle rigidity, high fever, autonomic dysfunction, and altered mental status. Prompt recognition and intervention are essential to prevent serious complications or death.

4. A 50-year-old man presents with severe epigastric pain radiating to his back, nausea, and vomiting. He has a history of heavy alcohol use. Laboratory tests reveal elevated serum amylase and lipase. What is the most likely diagnosis?

• A. Acute cholecystitis
• B. Peptic ulcer disease
• C. Acute pancreatitis
• D. Gastroesophageal reflux disease

Correct answer: C

Rationale: The patient's history of heavy alcohol use, severe epigastric pain radiating to the back, nausea, vomiting, and elevated serum amylase and lipase levels are classic signs of acute pancreatitis. Alcohol consumption is a common predisposing factor for pancreatitis, leading to inflammation of the pancreas. The clinical presentation, along with the laboratory findings, strongly support the diagnosis of acute pancreatitis in this patient.

5. A client who is 2 days postoperative reports severe pain and swelling in the right leg. The nurse notes that the leg is warm and red. What is the nurse's priority action?

• A. Apply a warm compress to the affected leg.
• B. Elevate the leg on pillows.
• C. Measure the circumference of the leg.
• D. Notify the healthcare provider immediately.

Correct answer: D

Rationale: The nurse's priority action in this situation is to notify the healthcare provider immediately. These symptoms, including severe pain, swelling, warmth, and redness in the leg, are indicative of deep vein thrombosis (DVT), a potentially serious condition. Prompt notification of the healthcare provider is crucial to initiate appropriate diagnostic tests and interventions to prevent complications associated with DVT. Applying a warm compress (Choice A) could worsen the condition by increasing blood flow. Elevating the leg (Choice B) might be contraindicated in DVT as it can dislodge a clot. Measuring the circumference of the leg (Choice C) is not the priority at this time compared to promptly involving the healthcare provider.

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