Nursing Elites

1. A client is admitted for an exacerbation of heart failure (HF) and is being treated with diuretics for fluid volume excess. In planning nursing care, which interventions should the nurse include? (Select all that apply)

• A. Encourage oral fluid intake of 3,000 ml/day
• B. Observe for evidence of hypokalemia
• C. Teach the client how to restrict dietary sodium
• D. Monitor PTT, PT, and INR lab values

Correct answer: B

Rationale: The correct interventions to include when a client with heart failure is being treated with diuretics for fluid volume excess are to observe for evidence of hypokalemia. Diuretics can lead to potassium loss, resulting in hypokalemia. Monitoring for this electrolyte imbalance is crucial. Encouraging oral fluid intake of 3,000 ml/day may exacerbate fluid volume excess in a client with heart failure. Teaching the client how to restrict dietary sodium is important in managing heart failure, but it is not directly related to the use of diuretics for fluid volume excess. Monitoring PTT, PT, and INR lab values is not typically associated with diuretic therapy for heart failure but rather with anticoagulant therapy.

2. 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.

3. When administering diazepam, a benzodiazepine, 10 mg IV push PRN for a client with alcohol withdrawal symptoms, which actions should the nurse implement? (Select all that apply)

• A. Protect the medication from light exposure
• B. Monitor for changes in level of consciousness
• C. Observe for onset of generalized bruising or bleeding
• D. Perform ongoing assessment of respiratory status

Correct answer: D

Rationale: When administering diazepam for a client with alcohol withdrawal symptoms, it is crucial to perform ongoing assessment of respiratory status. Diazepam can lead to respiratory depression, emphasizing the need for continuous monitoring to detect any signs of respiratory distress early. Protecting the medication from light exposure is a general guideline for some drugs but is not a specific concern for diazepam. Observing for bruising or bleeding is not directly associated with the administration of diazepam for alcohol withdrawal symptoms, making choices A and C incorrect.

4. After receiving report, which client should the nurse assess last?

• A. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
• B. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed
• C. An older client with a distended abdomen and no drainage from the nasogastric tube
• D. An adult client with rectal tube draining clear pale red liquid drainage

Correct answer: D

Rationale: The correct answer is D because the client with rectal tube drainage of clear pale red liquid is likely to be the least urgent since this is a normal post-operative finding. Clear pale red liquid drainage from a rectal tube is typically not a cause for immediate concern. Choices A, B, and C present clients with concerning signs that may require more immediate assessment and intervention. A client with dark red drainage on a postoperative dressing may indicate active bleeding, a client with a compressed Jackson-Pratt drain bulb may have inadequate drainage resulting in complications, and a client with a distended abdomen and no drainage from the nasogastric tube may be experiencing gastrointestinal issues that need prompt evaluation.

5. A client who sustained a pellet gun injury with a resulting comminuted skull fracture is admitted overnight for observation. Which assessment finding obtained two hours after admission necessitates immediate intervention?

• A. The client complains of a throbbing headache rated 10 (on a scale of 1 to 10)
• B. The client repeatedly falls asleep while talking with the nurse
• C. The entry site has a slow trickle of bright red blood
• D. The entry site appears reddened and edematous

Correct answer: B

Rationale: In a client with a pellet gun injury and a comminuted skull fracture, repeatedly falling asleep while talking with the nurse is a concerning sign. It can indicate increased intracranial pressure or a deteriorating condition, requiring immediate intervention. The other options, such as a throbbing headache (choice A), slow trickle of bright red blood at the entry site (choice C), or reddened and edematous entry site (choice D), while important to monitor, do not directly indicate a need for immediate intervention as much as the client falling asleep repeatedly while talking does.

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