Nursing Elites

1. A client reports pain after medication administration. What is the next best step for the nurse?

• A. Reassess the client’s pain
• B. Increase the pain medication dose
• C. Apply a cold compress
• D. Contact the healthcare provider

Correct answer: A

Rationale: The correct answer is to reassess the client’s pain. Reassessment is essential to evaluate the effectiveness of the initial intervention. By reassessing, the nurse can determine if the current pain management plan is adequate or if further interventions are required. Increasing the pain medication dose without reassessment can lead to overmedication and potential adverse effects. Applying a cold compress may not address the underlying cause of the pain and should be based on a proper assessment. Contacting the healthcare provider should be considered if the reassessment indicates a need for further evaluation or intervention beyond the nurse's scope of practice.

2. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which laboratory finding is most indicative of this condition?

• A. Serum glucose of 180 mg/dL
• B. Blood pH of 7.30
• C. Positive urine ketones
• D. Serum bicarbonate of 25 mEq/L

Correct answer: C

Rationale: The correct answer is C: Positive urine ketones. In diabetic ketoacidosis (DKA), the body breaks down fat for energy due to a lack of insulin, leading to ketone production. Positive urine ketones are a hallmark laboratory finding in DKA as they directly reflect the presence of ketosis. Choice A, serum glucose of 180 mg/dL, may be elevated in DKA, but it is not specific to this condition. Choice B, blood pH of 7.30, often shows acidosis in DKA, but urine ketones are more specific to the presence of ketosis. Choice D, serum bicarbonate of 25 mEq/L, would typically be low in DKA due to acidosis rather than elevated.

3. When teaching a diabetic client about foot care, what information is most important?

• A. Inspect feet daily
• B. Wear cotton socks
• C. Use lukewarm water to wash feet
• D. Cut nails straight across

Correct answer: A

Rationale: Inspecting feet daily is crucial for diabetic clients as it can help prevent complications like infections and ulcers. This practice allows for early detection of any foot issues, enabling timely intervention. While wearing cotton socks (choice B) is beneficial as they absorb moisture and reduce the risk of fungal infections, it is not as critical as daily foot inspection. Using lukewarm water to wash feet (choice C) is important to prevent burns or skin damage in diabetic clients with decreased sensation, but it is not as crucial as daily foot inspection. Cutting nails straight across (choice D) is essential to prevent ingrown nails, but it is not the most important information when educating diabetic clients about foot care.

4. The nurse is caring for a client with chronic liver disease. Which lab value is most concerning?

• A. Elevated AST and ALT
• B. Decreased albumin level
• C. Elevated bilirubin level
• D. Prolonged PT/INR

Correct answer: D

Rationale: The correct answer is D, prolonged PT/INR. In a client with chronic liver disease, a prolonged PT/INR is the most concerning lab value. This indicates impaired liver function, leading to a higher risk of bleeding. Elevated AST and ALT (choice A) are indicators of liver damage but do not directly assess the risk of bleeding. Decreased albumin level (choice B) reflects impaired liver function but is not as directly related to bleeding risk as a prolonged PT/INR. Elevated bilirubin level (choice C) is a sign of liver dysfunction, specifically related to bile metabolism, and while important, it is not as directly associated with bleeding risk as a prolonged PT/INR in the context of chronic liver disease.

5. The client is diagnosed with pneumonia. Which intervention is most effective in promoting airway clearance?

• A. Administer bronchodilators as prescribed
• B. Encourage increased fluid intake
• C. Perform chest physiotherapy
• D. Provide humidified oxygen

Correct answer: B

Rationale: Encouraging increased fluid intake is the most effective intervention in promoting airway clearance for a client with pneumonia. Increasing fluid intake helps to thin respiratory secretions, making it easier for the client to clear the airways. Administering bronchodilators may help with bronchospasm but does not directly promote airway clearance. Chest physiotherapy may be beneficial but is not the first-line intervention for promoting airway clearance in pneumonia. Providing humidified oxygen can improve oxygenation but does not directly address airway clearance.

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