Nursing Elites

1. A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?

• A. Administer regular insulin intravenously.
• B. Give oral hypoglycemic agents.
• C. Administer sodium bicarbonate.
• D. Provide a high-calorie diet.

Correct answer: A

Rationale: The priority nursing action for a patient with type 1 diabetes mellitus admitted with diabetic ketoacidosis (DKA) is to administer regular insulin intravenously. Insulin helps to lower blood glucose levels and correct acidosis, which are critical in managing DKA. Administering oral hypoglycemic agents is not appropriate in the acute setting of DKA as they may not work quickly enough compared to intravenous insulin. While sodium bicarbonate may be used to correct acidosis, insulin administration is the priority to address both hyperglycemia and acidosis simultaneously. Providing a high-calorie diet is not suitable initially in DKA management; the main focus is on stabilizing the patient's condition through insulin therapy and fluid/electrolyte correction.

2. A client in acute renal failure has a serum potassium level of 6.3 mEq/L. What intervention can the nurse expect the healthcare provider to prescribe?

• A. Nitrofurantoin (Macrodantin) orally.
• B. Erythropoietin (Epogen) intravenously.
• C. Kayexalate retention enema.
• D. Azathioprine (Imuran) orally.

Correct answer: C

Rationale: In acute renal failure with high serum potassium levels, the healthcare provider is likely to prescribe a Kayexalate retention enema. Kayexalate is a medication used to lower elevated potassium levels by promoting potassium excretion through the gastrointestinal tract, thus aiding in the management of hyperkalemia in clients with renal failure.

3. What dietary advice should the nurse provide to help reduce the occurrence of hot flashes in a post-menopausal client?

• A. Increase intake of spicy foods.
• B. Limit caffeine and alcohol consumption.
• C. Consume a high-protein diet.
• D. Eat more dairy products.

Correct answer: B

Rationale: Limiting caffeine and alcohol consumption is recommended to help reduce the frequency of hot flashes in post-menopausal individuals. Caffeine and alcohol can trigger hot flashes and worsen their occurrence. Encouraging the client to reduce these stimulants in their diet may help alleviate hot flashes and improve their quality of life.

4. The client is receiving intravenous vancomycin. Which assessment finding should the nurse report immediately?

• A. Red man syndrome.
• B. Blood pressure of 130/80 mm Hg.
• C. Mild itching at the IV site.
• D. Nausea and vomiting.

Correct answer: A

Rationale: Red man syndrome is a severe and potentially life-threatening reaction to vancomycin characterized by flushing, rash, and hypotension. Immediate intervention is required to prevent further complications such as anaphylaxis. Therefore, the nurse should report this finding immediately to ensure prompt treatment and prevent serious adverse effects.

5. A 9-year-old female client was recently diagnosed with diabetes mellitus. Which symptom will her parents most likely report?

• A. Refuses to eat her favorite meals at home.
• B. Drinks more soft drinks than previously.
• C. Voids only one or two times per day.
• D. Gained 10 pounds within one month.

Correct answer: B

Rationale: The correct answer is B. Increased thirst and fluid intake, such as drinking more soft drinks than previously, is a common symptom of diabetes mellitus in children. This increased thirst is due to the body trying to eliminate excess sugar through urination, leading to dehydration and the need for more fluids. The other choices are less likely to be directly related to the diagnosis of diabetes mellitus in this scenario.

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