Nursing Elites

1. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?

• A. Administer intravenous antibiotics
• B. Apply warm moist packs every two hours
• C. Elevate the right foot on two pillows
• D. Teach the client about skin and foot care

Correct answer: A

Rationale: Administering intravenous antibiotics is the priority intervention in this scenario. Cellulitis is a bacterial skin infection that requires prompt treatment with antibiotics to prevent its spread and potential complications. While warm moist packs and elevation can be beneficial as adjunct measures, they are not the initial priority. Teaching about skin and foot care is important, but it can be addressed after stabilizing the acute condition with antibiotics.

2. For a patient with a history of liver disease, which type of diet is most appropriate?

• A. High-protein
• B. High-carbohydrate
• C. Low-protein
• D. Low-fat

Correct answer: D

Rationale: For a patient with a history of liver disease, a low-fat diet is most appropriate. Liver disease can impair fat metabolism, leading to fat accumulation in the liver cells and worsening the condition. A low-fat diet helps reduce stress on the liver and manage symptoms associated with liver disease. High-protein diets may not be suitable for individuals with liver disease as they can increase the risk of hepatic encephalopathy. High-carbohydrate diets may lead to insulin resistance and fat accumulation in the liver. While protein restriction may be necessary in some cases, a balanced intake of high-quality protein is essential for maintaining muscle mass and overall health, making a low-protein diet not the most appropriate choice for all patients with liver disease.

3. A client is transferred from the emergency department to the locked psychiatric unit after attempting suicide by taking 200 acetaminophen (Tylenol) tablets. The client is now awake and alert but refuses to speak with the nurse. In this situation, the nurse’s first priority is to:

• A. Establish a rapport to foster trust
• B. Place the client in full restraints
• C. Try to communicate with the client in writing
• D. Ensure safety by initiating suicide precautions

Correct answer: D

Rationale: In this scenario, the nurse's highest priority should be to ensure the client's safety by initiating suicide precautions. Given the history of a suicide attempt by taking a large number of acetaminophen tablets, there is a high risk of further self-harm. Placing the client in full restraints without assessing the situation properly may escalate anxiety and hinder therapeutic communication. Trying to communicate with the client in writing could be an option but ensuring immediate safety takes precedence. Establishing rapport is essential for building trust and therapeutic relationship, but safety concerns must be addressed first in this critical situation.

4. Which nursing action(s) can result in disciplinary action by state boards of nursing?

• A. Release of client health information to a client’s neighbor
• B. Delegation of a dressing change to unlicensed assistive personnel (UAP)
• C. Release of client health information to the client’s durable power of attorney
• D. A, B

Correct answer: D

Rationale: The correct answer is D. Disclosing client health information to unauthorized individuals, such as a client's neighbor (choice A) or improper delegation of nursing tasks to unlicensed personnel like UAPs (choice B), are violations of patient confidentiality and safety. Releasing client health information to the client's durable power of attorney (choice C) is a legal and appropriate action, not warranting disciplinary action. Therefore, choices A and B can result in disciplinary action by state boards of nursing, making option D the correct answer.

5. The client is admitted to the emergency department complaining of acute epigastric pain and reports vomiting a large amount of bright red blood at home. Which interventions should the nurse implement?

• A. Assess the client’s vital signs
• B. Start an IV with an 18-gauge needle
• C. Begin iced saline lavage
• D. A, B

Correct answer: D

Rationale: The correct interventions for a client presenting with acute epigastric pain and vomiting bright red blood are to assess the client’s vital signs and start an IV with an 18-gauge needle. Assessing vital signs helps in determining the client's current condition and response to treatment, while starting an IV is crucial for administering medications and fluids. Beginning iced saline lavage is not appropriate in this situation as the priority is to stabilize the client and address potential bleeding. Therefore, options A and B are correct choices, making option D the most appropriate answer.

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