Nursing Elites

1. A client with a history of diabetes mellitus is admitted with diabetic ketoacidosis (DKA). Which finding requires immediate intervention?

• A. Blood glucose of 200 mg/dL.
• B. Serum bicarbonate of 20 mEq/L.
• C. Blood pressure of 140/90 mm Hg.
• D. Urine output of 50 mL in 4 hours.

Correct answer: D

Rationale: In a client with diabetic ketoacidosis (DKA), urine output of 50 mL in 4 hours indicates oliguria, which is a concerning sign of decreased renal perfusion and potential renal failure. This finding requires immediate intervention to prevent further deterioration of kidney function.\n\nChoice A (Blood glucose of 200 mg/dL) is elevated but not the most urgent concern in this scenario. Choice B (Serum bicarbonate of 20 mEq/L) reflects metabolic acidosis, which is expected in DKA but does not require immediate intervention. Choice C (Blood pressure of 140/90 mm Hg) is slightly elevated but not acutely concerning in the context of DKA.

2. During a home visit, the nurse observes an elderly client with disabilities slip and fall. What action should the nurse take first?

• A. provide the client with 4 ounces of orange juice
• B. call 911 to summon emergency assistance
• C. check the client for lacerations or fractures
• D. assess the client's blood sugar level

Correct answer: C

Rationale: The correct action for the nurse to take first after an elderly client with disabilities slips and falls is to check the client for lacerations or fractures. This is crucial to assess the extent of injuries and provide appropriate medical attention promptly. Option A, providing orange juice, is not a priority in this situation and does not address the potential injuries. While calling 911 (Option B) may be necessary, assessing for immediate injuries takes precedence. Assessing the client's blood sugar level (Option D) is not the immediate priority after a fall unless there is a specific indication or suspicion of hypoglycemia.

3. A first-grade boy is sent to the school nurse after he fainted while playing tag during recess. When he arrives in the clinic he is alert and oriented and his vital signs include temperature of 97.8°F, pulse 96 bpm, respirations 15 breaths/minute, and blood pressure 80/56 mmHg. Which intervention is most important for the nurse to implement?

• A. request transport of the child to his pediatrician's office
• B. call the child's parents and send him home for the day
• C. compare the child's body mass index to normal values
• D. measure the child's pulse and blood pressure every 15 minutes

Correct answer: D

Rationale: In this scenario, the most important intervention for the nurse to implement is to measure the child's pulse and blood pressure every 15 minutes. The child experienced a syncopal episode (fainting) which could be due to various reasons, including dehydration or cardiac issues. Monitoring vital signs frequently will help detect any changes that may indicate underlying health issues. Requesting transport to the pediatrician's office or sending the child home without continuous monitoring may not provide immediate assessment and intervention. Comparing the child's body mass index to normal values is not relevant in addressing the immediate concern of monitoring vital signs after a syncopal episode.

4. A client with a history of alcohol abuse is admitted with cirrhosis. Which finding requires immediate intervention?

• A. Jaundice.
• B. Ascites.
• C. Peripheral edema.
• D. Spider angiomas.

Correct answer: C

Rationale: Peripheral edema in a client with cirrhosis can indicate fluid overload and worsening liver function, necessitating immediate intervention to prevent further complications such as respiratory distress, cardiac issues, or renal impairment. Jaundice (choice A) is a common manifestation of cirrhosis but may not require immediate intervention unless severe. Ascites (choice B) is also a common complication of cirrhosis that may require intervention but is not as urgent as addressing peripheral edema. Spider angiomas (choice D) are typically benign skin lesions associated with cirrhosis but do not require immediate intervention unless bleeding or rupture occurs.

5. The nurse is providing care for a client with syndrome of inappropriate antidiuretic hormone (SIADH). Which laboratory result requires immediate intervention?

• A. Serum sodium of 140 mEq/L.
• B. Serum potassium of 4.5 mEq/L.
• C. Serum osmolality of 280 mOsm/kg.
• D. Serum sodium of 130 mEq/L.

Correct answer: D

Rationale: The correct answer is D: Serum sodium of 130 mEq/L. In SIADH, there is excess release of antidiuretic hormone leading to water retention and dilutional hyponatremia. A serum sodium level of 130 mEq/L indicates severe hyponatremia, which can result in neurological symptoms, such as confusion, seizures, and coma. Therefore, immediate intervention is required to prevent further complications. Choice A, a serum sodium of 140 mEq/L, is within the normal range and does not require immediate intervention. Choice B, serum potassium of 4.5 mEq/L, is also within the normal range and is not directly related to SIADH. Choice C, serum osmolality of 280 mOsm/kg, is a measure of the concentration of solutes in the blood and may not be the most critical parameter to address in a client with SIADH and severe hyponatremia.

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