Nursing Elites

1. When implementing patient teaching for a patient admitted with hyperglycemia and newly diagnosed diabetes mellitus scheduled for discharge the second day after admission, what is the priority action for the nurse?

• A. Instruct about the increased risk of cardiovascular disease.
• B. Provide detailed information about dietary glucose control.
• C. Teach glucose self-monitoring and medication administration.
• D. Give information about the effects of exercise on glucose control.

Correct answer: C

Rationale: The priority action for the nurse when time is limited is to focus on essential teaching. In this scenario, the patient should be educated on how to self-monitor glucose levels and administer medications to control glucose levels. This empowers the patient with immediate skills for managing their condition. Instructing about the increased risk of cardiovascular disease (choice A) is important but not as urgent as teaching self-monitoring and medication administration. Providing detailed information about dietary glucose control (choice B) can be beneficial but is secondary to ensuring the patient can monitor and manage their glucose levels. Teaching about the effects of exercise (choice D) is relevant but not as critical as immediate self-monitoring and medication administration education.

2. A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?

• A. Glasgow Coma Scale
• B. Assess pulses, paresthesia, and paralysis distal to the right knee
• C. Assess pulses, paresthesia, and paralysis proximal to the right knee
• D. Optic nerve using an ophthalmoscope

Correct answer: B

Rationale: In this scenario, the nurse should assess pulses, paresthesia, and paralysis distal to the right knee to evaluate for neurovascular compromise. This assessment helps determine the perfusion and sensation of the lower extremity, which is crucial in identifying potential vascular or nerve damage that may be causing the client's symptoms.

3. Which of the following statements about Helicobacter pylori (H. pylori) is false?

• A. H. pylori does not invade the gastric or duodenal epithelium
• B. H. pylori stimulates gastric acid secretion
• C. Eradication of H. pylori prevents adenocarcinoma of the stomach
• D. H. pylori produces a urease that splits urea into ammonia and CO2

Correct answer: C

Rationale: H. pylori is known to reside in the mucus layer of the stomach and does not invade the epithelium. It produces urease that splits urea into ammonia and CO2. This action helps in neutralizing the acidic environment and allows H. pylori to survive. Additionally, urease activity can be detected in diagnostic tests for H. pylori. The stimulation of gastric acid secretion and disruption of the protective mucus layer are mechanisms by which H. pylori promotes injury. While eradicating H. pylori infection has been associated with a decreased risk of developing gastric cancer, it does not prevent adenocarcinoma of the stomach entirely.

4. When assessing a client with a chest tube connected to suction, which observation indicates that the chest tube is functioning properly?

• A. Continuous bubbling in the water seal chamber.
• B. Intermittent bubbling in the suction control chamber.
• C. No fluctuation in the water seal chamber.
• D. Steady bubbling in the suction control chamber.

Correct answer: D

Rationale: Steady bubbling in the suction control chamber is the correct observation that indicates the chest tube is functioning properly. This steady bubbling signifies that the suction is actively maintaining the desired pressure level within the system, ensuring proper drainage and lung re-expansion. Continuous bubbling in the water seal chamber, intermittent bubbling in the suction control chamber, or no fluctuation in the water seal chamber are not indicative of optimal chest tube function and may require further assessment or intervention.

5. A client with a history of peptic ulcer disease is admitted with severe abdominal pain. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Bowel sounds active in all quadrants.
• B. Blood pressure of 110/70 mm Hg.
• C. Rigid, board-like abdomen.
• D. Heart rate of 90 beats per minute.

Correct answer: C

Rationale: A rigid, board-like abdomen is a sign of peritonitis, a serious complication of peptic ulcer disease that can lead to sepsis and requires immediate intervention. This finding indicates a potential emergency situation that needs urgent medical attention to prevent further complications.

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