Nursing Elites

1. In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?

• A. Pulse oximetry
• B. Blood glucose
• C. Arterial blood gases
• D. Serum electrolytes

Correct answer: B

Rationale: Deep, rapid respirations (Kussmaul respirations) and lethargy are signs of diabetic ketoacidosis (DKA), which occurs in uncontrolled type 1 diabetes. Checking the blood glucose is the priority to confirm hyperglycemia and guide immediate treatment. Pulse oximetry is not the priority in this situation as the issue is related to altered glucose levels, not oxygenation. Arterial blood gases and serum electrolytes may be important later in the management of DKA but are not the initial priority compared to confirming and addressing the hyperglycemia.

2. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

• A. Limit the effects of tissue damage
• B. Relieve pain and anxiety
• C. Prevent arrhythmias
• D. Reduce anxiety

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

3. While assessing several clients in a long-term health care facility, which client is at the highest risk for developing decubitus ulcers?

• A. A 79-year-old malnourished client on bed rest
• B. An obese client who uses a wheelchair
• C. A client who had 3 episodes of incontinent diarrhea
• D. An 80-year-old ambulatory diabetic client

Correct answer: A

Rationale: The correct answer is A: A 79-year-old malnourished client on bed rest. This client is at the highest risk for developing decubitus ulcers due to being malnourished and on bed rest, leading to decreased mobility and poor nutrition. This combination puts the client at significant risk for skin breakdown and pressure ulcers. Choice B is incorrect because although obesity is a risk factor for developing pressure ulcers, immobility and poor nutrition are higher risk factors. Choice C is incorrect as incontinence can contribute to skin breakdown but is not as high a risk factor as immobility and poor nutrition. Choice D is incorrect as an ambulatory client, even if diabetic, has better mobility than a bedridden client and is at lower risk for developing decubitus ulcers.

4. What breakfast selection indicates appropriate dietary management for osteoporosis?

• A. Pancakes with syrup and orange juice
• B. Bagel with jelly and skim milk
• C. Eggs with sausage and whole milk
• D. French toast with butter and syrup

Correct answer: B

Rationale: The correct answer is B. A bagel with jelly and skim milk is a calcium-rich and low-fat option that aligns with the dietary recommendations for managing osteoporosis. Osteoporosis is a condition characterized by weak and brittle bones, so it is essential to consume an adequate amount of calcium while avoiding excess fat intake. Choices A, C, and D are not ideal for osteoporosis management as they either lack sufficient calcium, contain high fat content, or both.

5. What instruction should the nurse include for a client prescribed nitroglycerin for a myocardial infarction?

• A. Take the medication only when experiencing severe chest pain.
• B. Store the medication in a dark container to protect it from light.
• C. Take the medication before engaging in physical activity that may trigger chest pain.
• D. Limit nitroglycerin use to no more than three doses in 15 minutes.

Correct answer: D

Rationale: The correct answer is D: 'Limit nitroglycerin use to no more than three doses in 15 minutes.' This instruction is crucial to prevent excessive use, which can lead to severe hypotension and other complications. Choice A is incorrect because nitroglycerin should also be used preventatively, not only during severe chest pain. Choice B is irrelevant and not a necessary instruction for nitroglycerin use. Choice C is incorrect as nitroglycerin is typically taken to prevent chest pain rather than waiting for an activity that may trigger it.

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