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 preparing a discharge teaching plan for a liver transplant client. Which instruction is most important to include in this plan?

• A. Ensure daily follow-up with the healthcare provider
• B. Take immunosuppressant medications as prescribed
• C. Avoid crowds for the first two months after surgery
• D. Return to work in three months

Correct answer: B

Rationale: The most critical instruction to include in the discharge teaching plan for a liver transplant client is to take immunosuppressant medications as prescribed. This is vital to prevent organ rejection and ensure the success of the transplant. While ensuring daily follow-up with the healthcare provider is important for monitoring progress, avoiding crowds for the first two months after surgery helps reduce the risk of infections but is not as crucial as medication adherence. Returning to work in three months is a consideration but not the most important aspect immediately post-transplant.

3. A client with cirrhosis develops ascites. What is the nurse’s priority intervention?

• A. Administer diuretics as prescribed.
• B. Restrict fluid intake to manage fluid overload.
• C. Position the client in Fowler’s position and assess for respiratory distress.
• D. Measure the client's abdominal girth daily.

Correct answer: B

Rationale: The correct answer is B: Restrict fluid intake to manage fluid overload. In a client with cirrhosis developing ascites, the priority intervention is to restrict fluid intake. This helps manage fluid overload, prevent further complications, such as respiratory distress or kidney impairment, and reduce the accumulation of ascitic fluid. Administering diuretics may be a part of the treatment plan, but the primary focus should be on fluid restriction. Positioning the client in Fowler’s position and measuring the abdominal girth are important interventions but not the priority when managing ascites in cirrhosis.

4. Following discharge teaching, a male client with a duodenal ulcer tells the nurse that he will drink plenty of dairy products, such as milk, to help coat and protect his ulcer. What is the best follow-up action by the nurse?

• A. Encourage the client to drink milk
• B. Review with the client the need to avoid foods that are rich in milk and cream
• C. Instruct the client to take antacids instead
• D. Advise the client to monitor their symptoms

Correct answer: B

Rationale: The client should be advised to avoid foods rich in milk and cream. Although they provide temporary relief, dairy products, especially milk, stimulate gastric acid secretion, which can exacerbate the symptoms of a duodenal ulcer. Encouraging the client to drink milk (Choice A) would be counterproductive and could worsen the condition. Instructing the client to take antacids (Choice C) may provide symptomatic relief but does not address the root cause of the issue. Advising the client to monitor their symptoms (Choice D) is vague and does not provide specific guidance on managing the duodenal ulcer. Therefore, the best action is to review with the client the need to avoid foods rich in milk and cream to ensure proper ulcer management.

5. A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states 'I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects.' The nurse should understand that

• A. A referral is needed to the psychiatrist who is to provide the client with answers
• B. The client has a right to know about the prescribed medications
• C. Such education is an independent decision of the individual nurse whether or not to teach clients about their medications
• D. Clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects

Correct answer: B

Rationale: The correct answer is B. The client has a legal right to be informed about their treatment, including medication uses and side effects, as part of informed consent. This helps ensure that the client can make an informed decision about their care. Choice A is incorrect because the nurse can provide the client with information about their medications. Choice C is incorrect as it is not an independent decision of the nurse but a professional responsibility to educate clients. Choice D is incorrect as knowledge about medication side effects can actually empower clients to manage their condition effectively.

Similar Questions