Nursing Elites

1. A 13-year-old girl, diagnosed with diabetes mellitus Type 1 at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

• A. Ate an extra peanut butter sandwich before gym class
• B. Incorrectly drew up and administered too much insulin
• C. Was not hungry, so she skipped eating lunch
• D. Has had a cold and ear infection for the past two days

Correct answer: B

Rationale: The correct answer is B. Incorrect insulin administration is a common cause of diabetic ketoacidosis. Administering too much insulin can lead to uncontrolled hyperglycemia, where the body starts breaking down fat for energy, resulting in the production of ketones. Choices A, C, and D are less likely to directly cause diabetic ketoacidosis. Eating an extra peanut butter sandwich, skipping lunch, or having a cold and ear infection would not directly lead to the metabolic derangements seen in diabetic ketoacidosis.

2. A client recovering from abdominal surgery is on a clear liquid diet. The nurse should identify which of the following as the most appropriate food choice for this diet?

• A. Chicken noodle soup
• B. Grape juice
• C. Cream of wheat
• D. Vanilla pudding

Correct answer: B

Rationale: Grape juice is the most appropriate choice for a clear liquid diet as it is a transparent fluid that is easily digested. Clear liquid diets aim to provide fluids and electrolytes while being easy on the digestive system. Choices A, C, and D are not suitable for a clear liquid diet as they are not in liquid form or do not meet the criteria of being easily digestible for someone recovering from abdominal surgery. Chicken noodle soup, cream of wheat, and vanilla pudding are not considered clear liquids and may not be well-tolerated by a client who has undergone abdominal surgery.

3. Based on the information provided in this client’s medical record during labor, which intervention should the nurse implement?

• A. Apply oxygen at 10 L per minute via mask
• B. Stop the oxytocin infusion
• C. Turn the client to the right lateral position
• D. Continue monitoring the progress of labor

Correct answer: C

Rationale: Turning the client to the right lateral position is essential as it can improve fetal oxygenation and uterine blood flow, promoting better labor outcomes. This intervention helps relieve pressure on blood vessels, enhancing blood flow to the placenta and improving oxygen supply to the fetus. Applying oxygen at a specific rate may not address the underlying issue of compromised blood flow and oxygenation. Stopping the oxytocin infusion is not the priority unless medically indicated as it can affect labor progression. While monitoring the progress of labor is important, actively addressing the compromised fetal oxygenation and uterine blood flow by changing the client's position takes precedence in this scenario.

4. The nurse is assessing a client with pulmonary edema who is reporting two-pillow orthopnea and paroxysmal nocturnal dyspnea. The nurse identifies rapid shallow respirations and the use of accessory muscles. Which action should the nurse include in the client’s plan of care?

• A. Administer the prescribed amiodarone (Cordarone) immediately
• B. Institute a daily fluid restriction while the client is in the hospital
• C. Perform a blood draw for serum Troponin, CK, and CK-MB levels
• D. Place the client in the Trendelenburg position to facilitate perfusion

Correct answer: A

Rationale: Administering amiodarone is appropriate if arrhythmias are present in the context of pulmonary edema, as it helps manage irregular heart rhythms. In this case, the client is experiencing symptoms related to respiratory distress, and amiodarone can address potential arrhythmias contributing to the condition. Options B and D are not directly related to managing symptoms of pulmonary edema and do not address the underlying cause of the client's distress. Option C, performing blood tests for cardiac enzymes, is important for assessing possible myocardial damage but does not directly address the immediate respiratory distress associated with pulmonary edema.

5. After administering a proton pump inhibitor (PPI), which action should the nurse take to evaluate the effectiveness of the medication?

• A. Ask the client about gastrointestinal pain
• B. Measure the client’s fluid intake and output
• C. Monitor the client’s serum electrolyte levels
• D. Auscultate for bowel sounds in all quadrants

Correct answer: A

Rationale: The correct answer is A: Ask the client about gastrointestinal pain. The effectiveness of a proton pump inhibitor (PPI) is best evaluated by assessing the relief of gastrointestinal symptoms, such as heartburn, acid reflux, or stomach pain. These medications work by reducing the production of stomach acid, so improvement in these symptoms indicates the effectiveness of the PPI. Choices B, C, and D are incorrect because they do not directly reflect the effectiveness of a PPI. Measuring fluid intake and output, monitoring serum electrolyte levels, and auscultating for bowel sounds are important for assessing hydration status, electrolyte balance, and gastrointestinal motility, respectively. However, they are not specific to evaluating PPI effectiveness.

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