Nursing Elites

1. A nurse is caring for a client who has Crohn's disease. Which of the following findings should the nurse expect?

• A. Weight gain.
• B. Bloody stools.
• C. Urinary retention.
• D. Abdominal distention.

Correct answer: B

Rationale: The correct answer is B: Bloody stools. Bloody stools are a common symptom of Crohn's disease, characterized by inflammation of the digestive tract. Weight gain (choice A) is less likely due to malabsorption issues associated with Crohn's disease. Urinary retention (choice C) is not directly related to Crohn's disease. Abdominal distention (choice D) may occur in Crohn's disease but is not as specific a finding as bloody stools.

2. A client who has a new diagnosis of type 2 diabetes mellitus is being taught about foot care by a nurse. Which of the following statements should the nurse include?

• A. Use lotion on your feet to prevent dry, cracked skin, avoiding application between the toes.
• B. Avoid soaking your feet in warm water daily to prevent dry skin.
• C. Trim your toenails straight across to prevent injury.
• D. Do not apply a heating pad to your feet if they feel cold.

Correct answer: C

Rationale: The correct answer is C. Trimming toenails straight across is essential for clients with diabetes to prevent the risk of ingrown toenails and injury. Using lotion on feet can be beneficial but should not be applied between the toes to avoid moisture buildup, which can lead to infections. Soaking feet in warm water can lead to dry skin, increasing the risk of cracks and other complications. Applying a heating pad to feet when they feel cold is not recommended for clients with diabetes due to impaired sensation, which can result in burns and other injuries.

3. A nurse is reviewing the laboratory values of a client who has diabetic ketoacidosis (DKA). Which of the following findings should the nurse report to the provider?

• A. Potassium 4.2 mEq/L
• B. Glucose 250 mg/dL
• C. Bicarbonate 20 mEq/L
• D. Sodium 135 mEq/L

Correct answer: B

Rationale: The correct answer is B. A glucose level of 250 mg/dL indicates hyperglycemia, which is expected in DKA. However, in the context of DKA management, persistent or worsening hyperglycemia can indicate inadequate treatment response or complications, necessitating further monitoring and intervention. Potassium levels are crucial in DKA due to the risk of hypokalemia, but a level of 4.2 mEq/L is within the normal range. Bicarbonate levels are typically low in DKA, making a value of 20 mEq/L consistent with the condition. Sodium levels of 135 mEq/L are also within normal limits and not a priority for immediate reporting in the context of DKA.

4. A nurse is caring for a client who has a new prescription for levothyroxine. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the medication?

• A. Calcium
• B. Sodium
• C. Thyroid-stimulating hormone (TSH)
• D. Magnesium

Correct answer: C

Rationale: The correct answer is C: Thyroid-stimulating hormone (TSH). Monitoring TSH levels is crucial to assess the effectiveness of levothyroxine in clients with hypothyroidism. TSH is produced by the pituitary gland and stimulates the thyroid gland to produce thyroid hormones. In hypothyroidism, where the thyroid gland is underactive, administering levothyroxine helps to normalize thyroid hormone levels. Monitoring TSH levels allows the healthcare provider to adjust the levothyroxine dosage to ensure that thyroid hormone levels are within the therapeutic range. Choices A, B, and D (Calcium, Sodium, and Magnesium) are not directly related to assessing the effectiveness of levothyroxine therapy in hypothyroidism and would not provide relevant information regarding the medication's efficacy.

5. A nurse is reviewing the medical record of a client who is at 30 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 140/90 mm Hg
• B. 1+ pitting edema in the lower extremities
• C. Weight gain of 2.3 kg (5 lb) in 1 week
• D. Mild headache

Correct answer: C

Rationale: A weight gain of 2.3 kg (5 lb) in 1 week can indicate worsening preeclampsia due to fluid retention, which can lead to serious complications. This finding should be reported promptly to the provider for further assessment and intervention. Blood pressure of 140/90 mm Hg is high but may not be an immediate concern for a client with preeclampsia at 30 weeks. 1+ pitting edema in the lower extremities is common in pregnancy, especially in the third trimester, and may not be a significant finding in isolation. A mild headache can be a common symptom in pregnancy and may not be indicative of worsening preeclampsia unless accompanied by other concerning signs.

Similar Questions