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. When assisting a client with bilateral casts on her hands with feeding, what action should the nurse take?

• A. Sit at the bedside when feeding the client
• B. Provide pureed foods
• C. Ensure feedings are provided at room temperature
• D. Offer the client a drink of fluid after every bite

Correct answer: A

Rationale: When assisting a client with bilateral casts on her hands with feeding, the nurse should sit at the bedside. This action is crucial to provide the client with the nurse's full attention during the feeding process. Sitting at the bedside helps avoid appearing rushed and ensures a safe and comfortable environment for the client. Choices B, C, and D are incorrect because while they may be relevant in other situations, the priority when assisting a client with bilateral casts on her hands is to ensure proper attention and a comfortable setting during feeding.

3. A healthcare professional is assessing a client who has deep-vein thrombosis (DVT). Which of the following findings should the professional expect?

• A. Swelling of the affected limb.
• B. Diminished peripheral pulses.
• C. Coolness of the affected limb.
• D. Redness and warmth of the affected limb.

Correct answer: D

Rationale: Redness and warmth of the affected limb are classic signs of deep-vein thrombosis (DVT) due to inflammation and increased blood flow. These symptoms occur as a result of the blood clot obstructing normal blood flow and causing localized inflammation in the affected limb. Swelling of the affected limb, diminished peripheral pulses, and coolness are not typically associated with DVT. Swelling can be present but is often accompanied by the characteristic redness and warmth. Diminished pulses and coolness are more indicative of arterial insufficiency rather than venous thrombosis.

4. A client with gout is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should increase my intake of purine-rich foods.
• B. I should decrease my intake of purine-rich foods.
• C. I should increase my intake of sodium-rich foods.
• D. I should decrease my intake of potassium-rich foods.

Correct answer: B

Rationale: The correct answer is B. Decreasing the intake of purine-rich foods is essential in managing gout as purines break down into uric acid, contributing to gout symptoms. Increasing purine-rich foods would exacerbate the condition by increasing uric acid levels. Therefore, choice A is incorrect. Choices C and D are also incorrect as increasing sodium-rich foods (choice C) is not recommended for gout management, and decreasing potassium-rich foods (choice D) is unrelated to gout.

5. A healthcare professional is preparing to perform nasotracheal suctioning for a client. Which of the following actions should the healthcare professional take?

• A. Suction during inhalation.
• B. Apply intermittent suction during insertion.
• C. Place the client in a supine position.
• D. Insert the catheter while the client is inhaling.

Correct answer: D

Rationale: Inserting the catheter while the client is inhaling helps to align the trachea and vocal cords, reducing the risk of trauma to the respiratory tract. This technique also facilitates easier passage of the catheter into the trachea, enhancing the effectiveness of the suctioning procedure.

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