Nursing Elites

1. When assessing a client with diabetes mellitus experiencing DKA, which of the following findings should the nurse expect?

• A. Tremors
• B. Urine retention
• C. Kussmaul respirations
• D. Bradypnea

Correct answer: C

Rationale: Kussmaul respirations are a type of deep and labored breathing pattern associated with severe metabolic acidosis, commonly observed in diabetic ketoacidosis (DKA). In DKA, the body tries to compensate for the acidic environment by increasing the respiratory rate, resulting in Kussmaul respirations. This helps eliminate excess carbon dioxide and reduce the acidity of the blood. Tremors (Choice A) are not typically associated with DKA. Urine retention (Choice B) is not a common finding in DKA; in fact, clients with DKA often have polyuria due to the osmotic diuresis caused by high blood glucose levels. Bradypnea (Choice D), which is abnormally slow breathing rate, is not a characteristic finding in DKA where the respiratory rate is usually increased to compensate for metabolic acidosis.

2. During an abdominal assessment, what is the correct sequence of steps for a healthcare provider to follow?

• A. Inspection, percussion, palpation, auscultation
• B. Percussion, auscultation, inspection, palpation
• C. Auscultation, palpation, inspection, percussion
• D. Inspection, auscultation, percussion, palpation

Correct answer: D

Rationale: During an abdominal assessment, the correct sequence of steps is inspection, auscultation, percussion, and palpation. This sequence is followed to prevent altering bowel sounds. Inspection allows for visual observation, followed by auscultation to listen for bowel sounds without causing disturbance, percussion to assess for tympany or dullness, and finally palpation to feel for any abnormalities or tenderness. Choice A is incorrect because palpation should come after percussion. Choice B is incorrect as auscultation should be performed after inspection. Choice C is incorrect because palpation should be the final step after percussion.

3. A client with a new diagnosis of cirrhosis is receiving dietary management education from a nurse. Which of the following statements should the nurse include in the teaching?

• A. You should increase your intake of sodium-rich foods.
• B. You should decrease your intake of sodium-rich foods.
• C. You should avoid foods that contain lactose.
• D. You should increase your intake of dairy products.

Correct answer: B

Rationale: Reducing the intake of sodium-rich foods is beneficial for managing fluid retention and symptoms of cirrhosis. Excessive sodium can lead to fluid buildup in the body, worsening edema and ascites commonly associated with cirrhosis. Therefore, advising the client to decrease their intake of sodium-rich foods is crucial in the dietary management of cirrhosis. Option A is incorrect as increasing sodium intake would exacerbate fluid retention. Option C is irrelevant to cirrhosis management unless the client has lactose intolerance. Option D is incorrect as increasing dairy product intake may not be suitable for all patients with cirrhosis, especially if they have complications like hepatic encephalopathy.

4. Prior to administering a blood transfusion, what should the healthcare professional do first?

• A. Prime the IV tubing with normal saline.
• B. Verify the client's identity.
• C. Obtain the blood product from the blood bank.
• D. Check the client's vital signs.

Correct answer: B

Rationale: Verifying the client's identity is the essential initial step before administering a blood transfusion. This action is crucial to confirm that the correct blood product is being administered to the right client, thereby preventing any potential errors or adverse reactions. Ensuring patient safety is paramount in healthcare, and verifying the client's identity is a fundamental safety measure that should always be prioritized.

5. A client with a new diagnosis of osteoporosis is being taught about dietary management. Which of the following statements should be included in the teaching?

• A. You should increase your intake of calcium-rich foods.
• B. You should decrease your intake of potassium-rich foods.
• C. You should avoid foods that contain vitamin D.
• D. You should increase your intake of high-sodium foods.

Correct answer: A

Rationale: The correct answer is A: 'You should increase your intake of calcium-rich foods.' Increasing intake of calcium-rich foods is essential for managing osteoporosis because calcium is necessary for bone health and density. Adequate calcium intake can help prevent further bone loss and reduce the risk of fractures in individuals with osteoporosis. Choices B, C, and D are incorrect. Decreasing intake of potassium-rich foods is not necessary for osteoporosis management. Avoiding foods that contain vitamin D is counterproductive since vitamin D is essential for calcium absorption. Increasing intake of high-sodium foods is not recommended as it can contribute to bone loss and negatively impact bone health.

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