Nursing Elites

1. What are the complications of diabetic ketoacidosis?

• A. Electrolyte imbalance and dehydration
• B. Hypoglycemia and increased urination
• C. Kidney failure and respiratory distress
• D. Liver failure and hypertension

Correct answer: A

Rationale: The correct answer is A: Electrolyte imbalance and dehydration. Diabetic ketoacidosis can lead to imbalances in electrolytes such as potassium, sodium, and chloride, as well as dehydration due to excess urination and vomiting. These complications should be managed promptly with appropriate fluids and insulin. Choices B, C, and D are incorrect. Hypoglycemia and increased urination are not typical complications of diabetic ketoacidosis; kidney failure and respiratory distress may occur in severe cases but are not the primary complications. Liver failure and hypertension are not directly associated with diabetic ketoacidosis.

2. A nurse is reviewing the record of a client with dementia. Which of the following findings should the nurse prioritize?

• A. Wandering at night
• B. A serum albumin level of 3.5 g/dL
• C. Urinary incontinence
• D. Restlessness and agitation

Correct answer: D

Rationale: Restlessness and agitation in clients with dementia could indicate a worsening condition and should be prioritized. While wandering at night and urinary incontinence are common issues in dementia patients, restlessness and agitation can signal acute distress or an unmet need, requiring immediate attention. Monitoring serum albumin levels is important for overall health but would not be the priority when assessing a client with dementia.

3. What is the correct way to assess for pitting edema?

• A. Press over the bony area for 5 seconds and release
• B. Press over the skin for 10 seconds and check for discoloration
• C. Press the area and check for the presence of rash
• D. Press the skin and assess for rebound tenderness

Correct answer: A

Rationale: The correct way to assess for pitting edema is to press over a bony area, typically the tibia, for 5 seconds and then release. This allows for the identification of pitting edema, characterized by an indentation that persists for a few seconds. Choice B is incorrect as pitting edema assessment does not involve checking for discoloration. Choice C is incorrect as the presence of a rash is not indicative of pitting edema. Choice D is incorrect as rebound tenderness is a different assessment used for abdominal conditions, not for pitting edema.

4. A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role?

• A. I will let the client know that I am available as the interpreter.
• B. I will receive a small fee for interpreting for this client.
• C. I am glad I am available today, but when I am not, you can use a family member.
• D. I will let the client know that an interpreter is unavailable during the night shift.

Correct answer: A

Rationale: Choice A is correct because the nurse should inform the client of their availability to interpret, ensuring that communication is clear and culturally appropriate. Choice B is incorrect as interpreters in healthcare settings usually do not receive fees for providing interpretation services. Choice C is incorrect because suggesting the use of a family member as an interpreter may not ensure accurate communication, as they may not be trained or impartial. Choice D is incorrect because stating that an interpreter is unavailable during the night shift does not address the current situation where the nurse has agreed to interpret for the client.

5. What is the first step in assessing a patient with suspected stroke?

• A. Check for facial droop
• B. Assess speech clarity
• C. Perform a neurological assessment
• D. Call for emergency assistance

Correct answer: D

Rationale: The correct answer is to call for emergency assistance (Option D) when assessing a patient with suspected stroke. Time is crucial in stroke management, and activating emergency services promptly can ensure timely access to specialized care such as stroke units and treatments like thrombolytic therapy. Checking for facial droop (Option A), assessing speech clarity (Option B), and performing a neurological assessment (Option C) are important steps in evaluating a stroke but should follow the immediate action of calling for emergency assistance. These initial assessments can help confirm the suspicion of a stroke and provide valuable information to healthcare providers when they arrive. However, the priority is to ensure the patient receives appropriate care without delay by activating emergency services.

Similar Questions