Nursing Elites

1. The nurse is caring for a client with diabetic ketoacidosis (DKA). Which intervention is most important?

• A. Administer insulin as prescribed.
• B. Monitor the client's urine output.
• C. Assess the client's level of consciousness.
• D. Obtain an arterial blood gas (ABG) sample.

Correct answer: A

Rationale: Administering insulin is the most crucial intervention in managing diabetic ketoacidosis. Insulin helps reduce blood glucose levels and correct metabolic acidosis, which are the primary issues in DKA. Monitoring urine output (Choice B) is important but not as critical as administering insulin. Assessing the client's level of consciousness (Choice C) is essential but does not directly address the underlying cause of DKA. Obtaining an arterial blood gas sample (Choice D) can provide valuable information but is not as urgent as administering insulin to address the immediate metabolic imbalance.

2. The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 90%
• B. Respiratory rate of 28 breaths per minute
• C. Tidal volume of 300 ml
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: The correct answer is C. A tidal volume of 300 ml is concerning in a client with ARDS on mechanical ventilation because it indicates hypoventilation, which can lead to inadequate gas exchange and worsening respiratory status. This finding requires immediate intervention to optimize ventilation and oxygenation. Options A, B, and D are not as critical in this scenario. An oxygen saturation of 90% may be acceptable depending on the client's baseline condition and the target range set by the healthcare provider. A respiratory rate of 28 breaths per minute is slightly elevated but may not be immediately alarming. A blood pressure of 110/70 mmHg is within normal limits and does not require urgent intervention.

3. A client with cirrhosis is admitted with hepatic encephalopathy. Which clinical finding is most concerning?

• A. Confusion and altered mental status
• B. Increased abdominal girth
• C. Yellowing of the skin
• D. Peripheral edema

Correct answer: A

Rationale: Confusion and altered mental status are the most concerning clinical findings in a client with hepatic encephalopathy. These symptoms indicate worsening liver function and potential neurological complications, requiring immediate medical attention. Increased abdominal girth may suggest ascites, yellowing of the skin can indicate jaundice, and peripheral edema may be related to fluid retention, but in the context of hepatic encephalopathy, confusion and altered mental status take precedence due to the risk of rapid deterioration and the need for prompt management.

4. The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. Which action should the nurse take?

• A. Encourage the UAP to remain in the client's room until the procedure is completed.
• B. Explain that the hand rub can be completed in less than 2 minutes.
• C. Inform the UAP that handwashing helps to promote better asepsis.
• D. Determine why the UAP was not wearing gloves in the client's room.

Correct answer: B

Rationale: The correct answer is B. Explaining that hand rubs can be effective with less time allows the UAP to perform the procedure more efficiently while maintaining asepsis. Choice A is incorrect because the UAP does not need to remain in the client's room until the procedure is completed. Choice C is incorrect as the UAP was using an alcohol-based gel hand cleaner, not handwashing. Choice D is incorrect as the scenario does not mention any issue with glove usage, so it is not relevant to the situation at hand.

5. The nurse reviews the laboratory findings of a client with an open fracture of the tibia. The white blood cell (WBC) count and erythrocyte sedimentation rate (ESR) are elevated. Before reporting this information to the healthcare provider, what assessment should the nurse obtain?

• A. Appearance of wound
• B. Pain level
• C. Presence of fever
• D. Mobility status

Correct answer: A

Rationale: The correct answer is A: Appearance of wound. Elevated WBC and ESR levels suggest a possible infection in the client with an open fracture. Assessing the wound's appearance is crucial to evaluate for signs of infection, such as redness, warmth, swelling, or drainage. By assessing the wound first, the nurse can provide important information to the healthcare provider regarding the potential infection, which may require immediate intervention. Choices B, C, and D are important assessments in caring for a client with an open fracture; however, in this scenario, the priority is to assess the wound for signs of infection due to the elevated WBC and ESR levels.

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