Nursing Elites

1. A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding requires immediate intervention?

• A. Epigastric tenderness.
• B. Bowel sounds are hypoactive.
• C. The client reports sudden, severe abdominal pain.
• D. Bowel sounds are hyperactive.

Correct answer: C

Rationale: The correct answer is C. Sudden, severe abdominal pain can indicate a perforated ulcer, which is a medical emergency requiring immediate intervention. Epigastric tenderness (choice A) may be expected in a client with peptic ulcer disease but does not necessarily require immediate intervention. Hypoactive bowel sounds (choice B) are concerning but not as urgent as sudden, severe abdominal pain. Hyperactive bowel sounds (choice D) are more indicative of conditions like gastroenteritis rather than a perforated ulcer, making it a less critical finding compared to sudden, severe abdominal pain.

2. A nurse starts classes for clients with type 2 diabetes. Which information would the nurse use as an outcome evaluation for the class?

• A. Parking convenience for attendees continues to be a major concern.
• B. Fasting blood glucose average readings were 20% lower by the end of classes.
• C. Discussion of food exchanges and calories was a well-attended class.
• D. Demonstrating the use of a blood glucose meter was an effective teaching strategy.

Correct answer: B

Rationale: A reduction in fasting blood glucose levels indicates the effectiveness of the diabetes management education provided. Monitoring blood glucose levels is a crucial aspect of diabetes management, and a decrease in average readings signifies improvement in managing blood sugar levels. Choices A, C, and D are not direct outcome evaluations related to the effectiveness of the education provided in managing diabetes. Parking convenience, attendance, and teaching strategies are not direct indicators of the impact on the clients' health outcomes.

3. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which laboratory result requires immediate intervention?

• A. Blood glucose of 250 mg/dL.
• B. Serum potassium of 3.5 mEq/L.
• C. Serum sodium of 135 mEq/L.
• D. Arterial blood pH of 7.30.

Correct answer: D

Rationale: An arterial blood pH of 7.30 indicates the client is in acidosis, which is a life-threatening condition in DKA. Immediate intervention is required to correct the acidosis and prevent further complications such as organ failure or coma. Blood glucose of 250 mg/dL is elevated but not an immediate threat to life in comparison to acidosis. Serum potassium of 3.5 mEq/L and serum sodium of 135 mEq/L are within normal ranges and do not warrant immediate intervention in the context of DKA.

4. The school nurse is developing an individualized healthcare plan for a student with type 1 diabetes. Which component is most important to include in the plan?

• A. a schedule for blood glucose monitoring
• B. a list of low-carbohydrate snacks
• C. a contact list of healthcare providers
• D. a log for recording insulin administration

Correct answer: A

Rationale: The correct answer is A: a schedule for blood glucose monitoring. Regular blood glucose monitoring is essential in managing type 1 diabetes as it helps in monitoring blood sugar levels, adjusting treatment plans, and preventing complications such as hypoglycemia or hyperglycemia. Choice B, a list of low-carbohydrate snacks, while important for managing blood sugar levels, is not as critical as consistent blood glucose monitoring. Choice C, a contact list of healthcare providers, though important for emergency situations, is not the most crucial component in managing daily care. Choice D, a log for recording insulin administration, is valuable for tracking insulin doses but does not directly address the immediate need for monitoring blood glucose levels.

5. A community health nurse is planning a program to reduce the incidence of heart disease in the community. Which intervention should the nurse prioritize?

• A. Distributing educational materials on heart-healthy diets
• B. Organizing free cholesterol screenings
• C. Holding workshops on stress management
• D. Partnering with local gyms to offer fitness classes

Correct answer: B

Rationale: The correct answer is B: Organizing free cholesterol screenings. This intervention is crucial because it helps identify individuals at risk for heart disease by assessing their cholesterol levels. High cholesterol is a significant risk factor for heart disease, and identifying it early can lead to timely interventions and medical care. Choices A, C, and D, while beneficial for overall health, may not directly address the specific risk factor of high cholesterol associated with heart disease. Distributing educational materials on heart-healthy diets (A) could be helpful in preventing heart disease, but identifying individuals already at risk is a more urgent need. Holding workshops on stress management (C) and partnering with local gyms for fitness classes (D) are important for overall health promotion but may not target the specific risk factor of high cholesterol as directly as organizing cholesterol screenings.

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