Nursing Elites

1. When caring for a client with diabetes insipidus (DI), it is most important for the nurse to include frequent assessment for which conditions in the client’s plan of care?

• A. Dry mucous membranes, hypotension
• B. Decreased appetite, headache
• C. Nausea and vomiting, muscle weakness
• D. Elevated blood pressure, petechiae

Correct answer: A

Rationale: Dry mucous membranes and hypotension are key indicators of dehydration in clients with diabetes insipidus. The excessive urination associated with DI can lead to fluid loss, resulting in dehydration. Therefore, monitoring for signs such as dry mucous membranes and hypotension is crucial to assess the client's hydration status. Choices B, C, and D are not directly related to the characteristic symptoms of DI and are less relevant in the context of this condition. Decreased appetite and headache (Choice B) are nonspecific symptoms that may occur in various conditions. Nausea, vomiting, and muscle weakness (Choice C) are not typical manifestations of DI. Elevated blood pressure and petechiae (Choice D) are not commonly associated with DI; instead, hypotension is more commonly observed due to volume depletion.

2. During a well-child check-up, what respiratory assessment finding should the nurse anticipate in a 3-year-old?

• A. A resting respiratory rate of 40 breaths per minute
• B. Bronchovesicular breath sounds in the peripheral lung fields
• C. Retractions in the intercostal spaces with each inspiration
• D. High-pitched whistling sounds over the bronchi

Correct answer: A

Rationale: A resting respiratory rate of 40 breaths per minute is within the expected range for a 3-year-old child. This is considered normal in this age group as their respiratory rate is generally higher compared to adults. Bronchovesicular breath sounds in the peripheral lung fields are not an expected finding in a 3-year-old. Retractions in the intercostal spaces with each inspiration indicate increased work of breathing and are abnormal. High-pitched whistling sounds over the bronchi are characteristic of wheezing, which is not typically expected in a healthy 3-year-old during a routine check-up.

3. The nurse is preparing an older client for discharge following cataract extraction. Which instruction should be included in the discharge teaching?

• A. Do not read with direct lighting for 6 weeks
• B. Avoid straining during stool passage, bending, or lifting heavy objects
• C. Irrigate conjunctiva with ophthalmic saline after applying antibiotic ointment
• D. Limit exposure to sunlight during the first 2 weeks while the cornea is healing

Correct answer: B

Rationale: The correct instruction to include in the discharge teaching for a client following cataract extraction is to 'Avoid straining during stool passage, bending, or lifting heavy objects.' This is crucial to prevent increased intraocular pressure after surgery, which can be harmful. Reading with direct lighting can strain the eyes but is not the primary concern post-cataract surgery. Irrigating the conjunctiva before applying antibiotic ointment is not a standard practice and may not be necessary. While limiting sunlight exposure is important for eye protection, it is secondary to avoiding activities that can increase intraocular pressure.

4. A 46-year-old male client who had a myocardial infarction 24 hours ago comes to the nurse’s station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which nursing problem should the nurse formulate?

• A. Anxiety related to treatment plan
• B. Deficient knowledge of lifestyle changes
• C. Ineffective coping related to denial
• D. Decisional conflict due to stress

Correct answer: C

Rationale: The correct answer is C: 'Ineffective coping related to denial.' The client's behavior of wanting to go home and feeling much better shortly after a myocardial infarction indicates denial of the severity of his condition. This denial can lead to ineffective coping mechanisms, hindering his recovery and treatment. Choices A, B, and D are incorrect because the client's behavior is not primarily driven by anxiety about the treatment plan, deficient knowledge of lifestyle changes, or decisional conflict due to stress, but rather by denial and ineffective coping mechanisms.

5. A client who had an intraosseous (IO) cannula placed by the healthcare provider for emergent fluid resuscitation is complaining of severe pain and numbness below the IO site. The skin around the site is pale and edematous. What action should the nurse take first?

• A. Discontinue the IO infusion
• B. Administer an analgesic via the IO site
• C. Elevate the extremity with the IO site
• D. Notify the healthcare provider

Correct answer: A

Rationale: The correct action for the nurse to take first is to discontinue the IO infusion. The client's symptoms of severe pain, numbness, pale skin, and edema below the IO site suggest a complication, such as extravasation or compartment syndrome. By discontinuing the infusion, further harm can be prevented. Administering an analgesic via the IO site or elevating the extremity would not address the underlying issue and could potentially worsen the condition. Notifying the healthcare provider can be done after stopping the infusion to seek further guidance or intervention.

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