Nursing Elites

1. What is a priority goal for the diabetic client who is taking insulin and experiencing nausea and vomiting from a viral illness or influenza?

• A. Ensuring adequate food intake.
• B. Managing personal health.
• C. Relieving pain.
• D. Increasing physical activity.

Correct answer: A

Rationale: Ensuring adequate food intake is a priority goal for a diabetic client taking insulin and experiencing nausea and vomiting due to a viral illness or influenza because maintaining proper nutrition is essential to prevent complications such as ketoacidosis. During illness, it is crucial for diabetic individuals to continue to consume appropriate amounts of food to maintain stable blood sugar levels and prevent hypoglycemia. Managing personal health (choice B) is important but not the priority in this situation. Relieving pain (choice C) may be necessary if present but is not the priority over ensuring food intake. Increasing physical activity (choice D) is not recommended during illness, especially when the individual is experiencing nausea and vomiting.

2. What is the primary nursing intervention for a patient experiencing an acute asthma attack?

• A. Administering bronchodilators.
• B. Administering antibiotics.
• C. Administering IV fluids.
• D. Administering corticosteroids.

Correct answer: A

Rationale: The correct answer is administering bronchodilators. During an acute asthma attack, the primary goal is to relieve airway constriction and bronchospasm to improve breathing. Bronchodilators, such as short-acting beta-agonists, are the cornerstone of treatment as they help dilate the airways quickly. Administering antibiotics (choice B) is not indicated unless there is an underlying bacterial infection. Administering IV fluids (choice C) may be necessary in some cases, but it is not the primary intervention for an acute asthma attack. Administering corticosteroids (choice D) is often used as an adjunct therapy to reduce airway inflammation, but it is not the primary intervention during the acute phase of an asthma attack.

3. The nurse is assessing an older adult with a pacemaker who leads a sedentary lifestyle. The client reports being unable to perform activities that require physical exertion. The nurse should further assess the client for which of the following?

• A. Left ventricular atrophy.
• B. Irregular heartbeats.
• C. Peripheral vascular occlusion.
• D. Pacemaker function.

Correct answer: A

Rationale: The correct answer is A: Left ventricular atrophy. Older adults who lead sedentary lifestyles are at risk of developing left ventricular atrophy, which can lead to decreased cardiac output during physical exertion. This condition can contribute to the client's inability to perform activities requiring physical exertion. Choice B, irregular heartbeats, may be a consideration due to the presence of a pacemaker, but the client's reported inability to perform physically exerting activities is more indicative of a structural issue like left ventricular atrophy rather than a rhythm-related problem. Peripheral vascular occlusion (Choice C) is less likely to be the cause of the client's symptoms compared to the cardiac-related issue of left ventricular atrophy. While assessing pacemaker function (Choice D) is important, the client's symptoms are more suggestive of a cardiac structural issue rather than a malfunction of the pacemaker.

4. In the staging process of Hodgkin's disease, what does Stage I indicate?

• A. Involvement of a single lymph node.
• B. Involvement of two or more lymph nodes on the same side of the diaphragm.
• C. Involvement of lymph node regions on both sides of the diaphragm.
• D. Involvement of diffuse disease of one or more extralymphatic organs.

Correct answer: A

Rationale: In the staging process of Hodgkin's disease, Stage I signifies the involvement of a single lymph node. This stage indicates localized disease with the disease being limited to a single lymph node or a group of adjacent nodes. Choices B, C, and D are incorrect because they describe more extensive involvement of lymph nodes, both sides of the diaphragm, or extralymphatic organs, which would correspond to higher stages in the staging system.

5. A client with bladder cancer who underwent a complete cystectomy with ileal conduit is being assessed by a nurse. Which assessment finding should prompt the nurse to urgently contact the healthcare provider?

• A. The ileostomy is draining blood-tinged urine.
• B. There is serous sanguineous drainage on the surgical dressing.
• C. The ileostomy stoma appears pale and cyanotic.
• D. Oxygen saturations are 92% on room air.

Correct answer: C

Rationale: A pale or cyanotic appearance of the ileostomy stoma indicates compromised circulation, which can lead to necrosis if not promptly addressed. On the other hand, blood-tinged urine and serous sanguineous drainage are common following a complete cystectomy with ileal conduit. These findings do not typically indicate an urgent issue. An oxygen saturation of 92% on room air is slightly below the normal range but does not warrant urgent healthcare provider contact unless accompanied by significant respiratory distress or other concerning symptoms.

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