Nursing Elites

1. Which self-care measure is most important for the nurse to include in the plan of care of a client recently diagnosed with type 2 diabetes mellitus?

• A. Maintaining a low-sugar diet
• B. Foot care
• C. Blood glucose monitoring
• D. Daily exercise

Correct answer: C

Rationale: Blood glucose monitoring is crucial for managing diabetes effectively. By monitoring blood sugar levels, individuals can understand how their lifestyle choices, medications, and diet affect their glucose levels. This information helps in making necessary adjustments to control blood sugar levels and prevent complications. While maintaining a low-sugar diet, foot care, and daily exercise are all important aspects of managing diabetes, blood glucose monitoring takes precedence as it provides real-time data for informed decision-making.

2. Which intervention should be prioritized by the nurse when assessing tissue perfusion post-above knee amputation (AKA)?

• A. Evaluate the closest proximal pulse.
• B. Observe color and amount of wound drainage.
• C. Observe for swelling around the stump.
• D. Assess the skin elasticity of the stump.

Correct answer: A

Rationale: The correct answer is to evaluate the closest proximal pulse when assessing tissue perfusion post-above knee amputation (AKA). Checking the closest proximal pulse provides the best indication of tissue perfusion in the extremities after an AKA procedure. Observing the color and amount of wound drainage (Choice B) is important for wound care but does not directly assess tissue perfusion. Observing for swelling around the stump (Choice C) may indicate inflammation or fluid accumulation but is not the most direct way to assess tissue perfusion. Assessing the skin elasticity of the stump (Choice D) is more related to skin integrity and wound healing rather than tissue perfusion.

3. A client with diabetes insipidus is admitted due to a pituitary tumor. What complication should the nurse monitor closely?

• A. Monitor for elevated blood pressure.
• B. Monitor for ketonuria.
• C. Monitor for peripheral edema.
• D. Monitor for hypokalemia.

Correct answer: D

Rationale: The correct answer is to monitor for hypokalemia. In diabetes insipidus, excessive urination can lead to electrolyte imbalances, particularly low potassium levels (hypokalemia). The loss of potassium through increased urination can result in muscle weakness, cardiac dysrhythmias, and other serious complications. Elevated blood pressure (Choice A) is not a typical complication of diabetes insipidus due to pituitary tumors. Ketonuria (Choice B) is more commonly associated with diabetes mellitus due to inadequate insulin levels. Peripheral edema (Choice C) is not a direct complication of diabetes insipidus.

4. While changing a client's chest tube dressing, the nurse notes a cracking sensation when gentle pressure is applied to the skin at the insertion site. What should the nurse do next?

• A. Apply a pressure dressing at the chest tube site.
• B. Administer an oral antihistamine per PRN order.
• C. Assess the client for allergies to topical cleaning agents.
• D. Measure the area of crackling and swelling.

Correct answer: D

Rationale: Measuring the area of crackling and swelling is essential in monitoring the progression of subcutaneous emphysema, which can result from air leaking into the tissues around the chest tube insertion site. This technique helps evaluate the extent of the issue and guides further interventions. Applying a pressure dressing (choice A) might exacerbate the condition by trapping more air. Administering an oral antihistamine (choice B) is not indicated for subcutaneous emphysema. Assessing for allergies to topical cleaning agents (choice C) is not the priority in this situation compared to evaluating and managing the subcutaneous emphysema.

5. A client with end-stage pulmonary disease requests 'no heroic measures' if she stops breathing. What should the nurse do next?

• A. Document the client's request in the medical record.
• B. Ask the client to discuss a DNR order with her healthcare provider.
• C. Consult the ethics committee for guidance.
• D. Discharge the client with no further discussion.

Correct answer: B

Rationale: The correct next step for the nurse is to ask the client to discuss a 'do not resuscitate' (DNR) order with her healthcare provider. While the client's wishes should be respected, it is essential to ensure proper documentation and legal protection by involving the healthcare provider in this decision-making process. Documenting the request in the medical record (Choice A) is important but should follow the discussion with the healthcare provider. Consulting the ethics committee (Choice C) may not be necessary at this stage and could delay the necessary actions. Discharging the client (Choice D) without further discussion is not appropriate and disregards the importance of addressing the client's wishes in a respectful and professional manner.

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