Nursing Elites

1. A nurse is caring for a client with a new diagnosis of type 1 diabetes. What is the most important aspect of teaching the nurse should focus on?

• A. The importance of regular exercise
• B. Proper administration of insulin
• C. Maintaining a low-carbohydrate diet
• D. Recognizing signs of hyperglycemia

Correct answer: B

Rationale: Proper administration of insulin is crucial for clients with type 1 diabetes as they are dependent on insulin for blood glucose control.

2. A client with asthma presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (SATA)

• A. Administer prescribed salmeterol (Serevent) inhaler.
• B. Assess the client for a tracheal deviation.
• C. Administer oxygen to maintain saturations above 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation suggests the client is using accessory muscles due to difficulty in moving air into the respiratory passages caused by airway narrowing. The presence of bilateral wheezing and decreased pulse oxygen saturation further support airway narrowing. In this situation, immediate intervention is necessary to improve oxygenation. Administering oxygen to maintain saturations above 94% is crucial to support oxygenation. While administering a rescue inhaler may be warranted, the priority in this scenario is ensuring adequate oxygenation to address the respiratory distress.

3. While caring for a client using O2 in the hospital, what assessment finding indicates that goals for a priority diagnosis are being met?

• A. 100% of meals being eaten by the client
• B. Intact skin behind the ears
• C. The client understanding the need for oxygen
• D. Unchanged weight for the past 3 days

Correct answer: B

Rationale: When a client is using oxygen, there is a risk for impaired skin integrity due to pressure from tubing. Intact skin behind the ears suggests that the client is not experiencing skin breakdown, meeting the goals for this diagnosis. The client's nutrition, understanding of oxygen therapy, and weight stability are important but do not directly relate to the priority diagnosis of skin integrity in this context.

4. The trauma unit nurse has received a report on a client who has multiple injuries following a motor vehicle crash. Which of the following actions should the nurse plan to take first?

• A. Evaluate chest expansion.
• B. Check pupillary response to light.
• C. Assess the capillary refill.
• D. Check the client's response to questions about place and time.

Correct answer: A

Rationale: In a client with multiple injuries following a motor vehicle crash, the priority is to assess for any compromised airway or breathing. Evaluating chest expansion helps the nurse determine if the client is having any difficulty breathing, which is essential for immediate intervention to maintain adequate oxygenation. Checking pupillary response, assessing capillary refill, and checking the client's orientation to place and time are important assessments but are of lower priority compared to ensuring the client's airway and breathing are intact.

5. A client who had coronary artery bypass grafting yesterday needs care. What actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (SATA)

• A. administer antibiotics every 4 hrs
• B. Encourage the client to use the spirometer every 4 hours.
• C. Ensure the client wears TED hose or sequential compression devices.
• D. Have the client rate pain on a 0-to-10 scale and report to the nurse.

Correct answer: C

Rationale: The nurse can delegate tasks such as assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs to the unlicensed assistive personnel (UAP). Using the spirometer should be encouraged every hour the day after surgery by the nurse. Assessing pain using a 0-to-10 scale is a nursing assessment. However, if the client reports pain, the UAP should inform the nurse for a more detailed assessment.

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