Nursing Elites

1. A client with chronic heart failure is admitted with shortness of breath and a new onset of confusion. Which intervention should the nurse implement first?

• A. Obtain a neurological assessment.
• B. Administer oxygen therapy.
• C. Monitor the client's urine output.
• D. Obtain an electrocardiogram (ECG).

Correct answer: A

Rationale: The correct answer is to obtain a neurological assessment. In a client with chronic heart failure presenting with confusion, the priority is to assess neurological status to rule out potential causes such as hypoxia or other complications. Administering oxygen therapy (Choice B) is important but assessing the neurological status takes precedence in this scenario. Monitoring urine output (Choice C) and obtaining an ECG (Choice D) may be necessary but are not the initial priority when a client presents with confusion alongside shortness of breath.

2. 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.

3. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen. Which intervention should the nurse implement first?

• A. Elevate the head of the bed.
• B. Administer oxygen therapy as prescribed.
• C. Assess the client's oxygen saturation.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: C

Rationale: Assessing the client's oxygen saturation is the first priority in managing a client with COPD receiving supplemental oxygen to ensure adequate oxygenation. Monitoring oxygen saturation levels helps in determining the effectiveness of the oxygen therapy and if adjustments are needed. Elevating the head of the bed can help with breathing but is not the first priority. Administering oxygen therapy as prescribed is important, but assessing the current oxygen saturation comes before administering more oxygen. Obtaining an arterial blood gas (ABG) sample may provide valuable information, but it is not the initial intervention needed in this situation.

4. An adult male who lives alone is brought to the Emergency Department by his daughter who found him unresponsive. Initial assessment indicated that the client has minimal respiratory effort, and his pupils are fixed and dilated. At the daughter's request, the client is intubated and ventilated. Which nursing intervention has the highest priority?

• A. Notify the client's minister of his condition.
• B. Determine if the client has an executed living will.
• C. Provide the family with information about palliative care.
• D. Discuss the possibility of organ donation with the family.

Correct answer: B

Rationale: Verifying whether the client has an executed living will is crucial to ensuring that his treatment preferences are followed. In this critical situation, knowing the client's wishes regarding medical interventions is paramount. Options A, C, and D are not the highest priority as they do not directly address the immediate need to determine the client's treatment preferences.

5. Which statement by the client indicates an understanding of the dietary modifications required with Cushing syndrome?

• A. I should increase my intake of foods high in calcium.
• B. I should avoid foods with high sodium content.
• C. I need to decrease my intake of vitamin D.
• D. I should consume more potassium-rich foods.

Correct answer: B

Rationale: The correct answer is B: 'I should avoid foods with high sodium content.' Clients with Cushing syndrome need to limit their sodium intake to help reduce fluid retention and manage hypertension, which are common complications of the syndrome. Increasing calcium intake (choice A) is not specifically indicated for Cushing syndrome. Decreasing vitamin D intake (choice C) is not a typical dietary modification for this condition. Consuming more potassium-rich foods (choice D) is not a primary focus of dietary modifications for Cushing syndrome.

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