Nursing Elites

1. A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer intravenous fluids as prescribed.
• B. Administer insulin as prescribed.
• C. Monitor the client's urine output.
• D. Check the client's blood glucose level.

Correct answer: B

Rationale: Administering insulin is the most important intervention in managing diabetic ketoacidosis. Insulin helps to reduce blood glucose levels and correct metabolic acidosis, which are critical in the treatment of DKA. While administering intravenous fluids is essential to manage dehydration, insulin takes precedence in treating the underlying cause of DKA. Monitoring urine output is important for assessing renal function but is not the primary intervention in managing DKA. Checking the client's blood glucose level is necessary, but administering insulin to reduce high blood glucose levels is the key priority in treating DKA.

2. A client with a nasogastric tube in place following gastric surgery reports nausea. What is the most appropriate nursing action?

• A. Irrigate the NG tube with 30 ml of normal saline.
• B. Administer an antiemetic as prescribed.
• C. Assess the NG tube for patency and reposition if necessary.
• D. Provide sips of water and reassess the client's symptoms.

Correct answer: C

Rationale: Assessing the NG tube for patency and repositioning it if necessary is the most appropriate action to relieve the client's nausea. Nausea in a client with a nasogastric tube can be due to the tube's malposition or blockage. Irrigating the NG tube with normal saline (Choice A) without assessing for patency or repositioning may worsen the situation. Administering an antiemetic (Choice B) can help manage symptoms but does not address the potential issue with the NG tube. Providing sips of water and reassessing symptoms (Choice D) may be contraindicated if there is a problem with the NG tube and could exacerbate the nausea.

3. A client with a history of atrial fibrillation is receiving warfarin (Coumadin). Which laboratory value should the nurse monitor closely?

• A. International Normalized Ratio (INR)
• B. Prothrombin time (PT)
• C. Serum sodium level
• D. Hemoglobin level of 12 g/dl

Correct answer: A

Rationale: The correct answer is A: International Normalized Ratio (INR). The INR should be closely monitored in a client receiving warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range to prevent both bleeding and clotting events. Choices B, C, and D are incorrect because while PT is used to monitor warfarin therapy, INR is a more precise indicator of therapeutic levels. Serum sodium level and hemoglobin level are not directly related to monitoring warfarin therapy.

4. In a client with cirrhosis admitted with jaundice and ascites, which laboratory value is most concerning?

• A. Serum bilirubin of 3.0 mg/dl
• B. Serum albumin of 3.0 g/dl
• C. Serum ammonia level of 80 mcg/dl
• D. Serum sodium level of 135 mEq/L

Correct answer: C

Rationale: A serum ammonia level of 80 mcg/dl is most concerning in a client with cirrhosis as it may indicate hepatic encephalopathy, requiring immediate intervention. Elevated ammonia levels are associated with impaired liver function and can lead to mental status changes. Serum bilirubin (Choice A) is elevated in cirrhosis but not as concerning for acute intervention as high ammonia levels. Serum albumin (Choice B) and serum sodium (Choice D) levels are important in cirrhotic patients but are not as directly associated with hepatic encephalopathy as ammonia levels.

5. When preparing to insert a nasogastric (NG) tube for a client admitted to the surgical unit with symptoms of a possible intestinal obstruction, which intervention should the nurse implement?

• A. Elevate the head of the bed 60 to 90 degrees
• B. Administer an antiemetic
• C. Prepare the client for surgery
• D. Provide oral care

Correct answer: A

Rationale: Elevating the head of the bed to 60 to 90 degrees is essential when inserting an NG tube. This position helps facilitate the passage of the tube through the esophagus into the stomach and reduces the risk of aspiration. Administering an antiemetic may be necessary to control nausea or vomiting, but it is not the primary intervention when inserting an NG tube. Preparing the client for surgery is not indicated solely for the insertion of an NG tube. Providing oral care is important for maintaining oral hygiene but is not directly related to inserting an NG tube.

Similar Questions