Nursing Elites

1. The client with diabetes mellitus type 1 has a fruity breath odor. What is the priority nursing action?

• A. Evaluate the client’s intake and output
• B. Measure the client’s capillary blood glucose
• C. Consult with the dietitian about the client’s diet
• D. Apply a pulse oximeter to the client’s finger

Correct answer: B

Rationale: Fruity breath odor in a client with diabetes mellitus type 1 can indicate ketoacidosis, a serious complication. Measuring the client’s capillary blood glucose is the priority nursing action in this scenario as it helps diagnose and manage the condition effectively. Evaluating intake and output may be important for overall assessment but not the priority when dealing with a potential emergency like ketoacidosis. Consulting with a dietitian about the client’s diet is important for long-term management but not the immediate priority. Applying a pulse oximeter is not relevant to addressing the fruity breath odor and suspected ketoacidosis.

2. An IV antibiotic is prescribed for a client with a postoperative infection. The medication is to be administered in 4 divided doses. What schedule is best for administering this prescription?

• A. 1000, 1600, 2200, 0400
• B. Give in equally divided doses during waking hours
• C. Administer with meals and a bedtime snack
• D. 0800, 1200, 1600, 2000

Correct answer: D

Rationale: The best schedule for administering the IV antibiotic in 4 divided doses is 0800, 1200, 1600, and 2000. This timing allows for equal spacing between doses, ensuring consistent therapeutic levels of the medication in the client's system. Choice A provides doses too close together, increasing the risk of medication errors and potential toxicity. Choice B's suggestion of giving doses during waking hours is vague and lacks specific timing, which may result in irregular dosing intervals. Choice C, administering with meals and a bedtime snack, is unrelated to the timing of the antibiotic doses and does not optimize the drug's effectiveness.

3. Which behavior is most likely to result in a breach of client confidentiality?

• A. Discussing a client’s condition during a teaching conference for nursing staff caring for the client
• B. Two nurses planning a client’s care while having lunch in the hospital cafeteria
• C. Nursing students on the same team discussing their assigned client’s conditions
• D. A registered nurse privately sharing personal feelings about a client with another nurse on the team

Correct answer: B

Rationale: The correct answer is B. Discussing client information in a public area, such as a cafeteria, may lead to breaches of confidentiality. Choice A involves discussing a client's condition in a professional setting, which is not likely to result in a breach as it is for educational purposes. Choice C involves nursing students discussing their assigned client's conditions, which is common in a learning environment and not necessarily a breach of confidentiality. Choice D involves a private conversation between healthcare professionals, which is less likely to result in a breach compared to discussing in a public area like a cafeteria where non-authorized individuals may overhear the conversation.

4. A male client, admitted to the mental health unit for a somatoform disorder, becomes angry because he cannot have his pain medication. He demands that the nurse call the healthcare provider and threatens to leave the hospital. What action should the nurse take?

• A. Place the client in seclusion per unit guidelines
• B. Administer a PRN prescription for lorazepam (Ativan)
• C. Call security to help ensure staff and client safety
• D. Ask what other methods he uses to deal with pain

Correct answer: C

Rationale: In this scenario, the nurse should prioritize ensuring safety. When a client becomes aggressive and threatens to leave, calling security is crucial to help maintain a safe environment for both staff and the client. Placing the client in seclusion (choice A) is not the appropriate initial action as it may escalate the situation further. Administering lorazepam (choice B) should not be the first response to behavioral issues. Asking about other pain management methods (choice D) is not the immediate priority when safety is at risk.

5. After changing to a new brand of laundry detergent, an adult male reports that he has a fine itchy rash. Which assessment finding warrants immediate intervention by the nurse?

• A. Bilateral Wheezing
• B. Urticaria
• C. Peripheral edema
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Urticaria. An itchy rash following a change in detergent may indicate an allergic reaction, specifically urticaria (hives), which requires immediate attention. Urticaria can be a sign of a severe allergic reaction, such as anaphylaxis. Bilateral wheezing (choice A) may suggest respiratory issues like asthma but is not directly related to the skin rash. Peripheral edema (choice C) and elevated blood pressure (choice D) are not typically associated with an allergic reaction to laundry detergent and would not be the priority assessment findings in this scenario.

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