Nursing Elites

1. The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days. What assessment is most important for the nurse to complete?

• A. Auscultate the client's bowel sounds
• B. Observe for edema around the ankles
• C. Measure the client's capillary glucose level
• D. Count the apical and radial pulses simultaneously

Correct answer: A

Rationale: The correct answer is to auscultate the client's bowel sounds. Hydromorphone is a potent opioid analgesic that can slow peristalsis and commonly cause constipation. By assessing the client's bowel sounds, the nurse can monitor for any signs of decreased bowel motility or potential constipation. Observing for edema (Choice B) is not directly related to hydromorphone administration. Measuring capillary glucose levels (Choice C) is not the priority in this situation. Counting the apical and radial pulses simultaneously (Choice D) is not specifically indicated in this scenario involving hydromorphone administration.

2. A young adult male is admitted to the emergency department with diabetic ketoacidosis (DKA). His pH is 7.25, HCO3 is 12 mEq/L, and blood glucose is 310 mg/dl. Which action should the nurse implement?

• A. Infuse sodium chloride 0.9% (normal saline)
• B. Prepare an emergency dose of glucagon
• C. Determine the last time the client ate
• D. Check urine for ketone bodies with a dipstick

Correct answer: A

Rationale: In DKA, restoring fluid balance with sodium chloride is a priority to address the dehydration and electrolyte imbalances present in this condition. Choice B, preparing an emergency dose of glucagon, is incorrect because DKA is characterized by insulin deficiency, not glucagon deficiency. Choice C, determining the last time the client ate, is not the immediate priority in managing DKA. Choice D, checking urine for ketone bodies with a dipstick, may help confirm the diagnosis of DKA but is not the most critical intervention at this time.

3. A client with a history of alcoholism is admitted with confusion, ataxia, and nystagmus. Which nursing intervention is a priority for this client?

• A. Monitor for signs of alcohol withdrawal.
• B. Administer thiamine as prescribed.
• C. Provide a quiet environment to reduce confusion.
• D. Initiate fall precautions.

Correct answer: B

Rationale: The correct answer is B: Administer thiamine as prescribed. Administering thiamine is crucial in clients with a history of alcoholism to prevent Wernicke's encephalopathy, which is characterized by confusion, ataxia, and nystagmus. Monitoring for signs of alcohol withdrawal (choice A) is important but not the priority. Providing a quiet environment (choice C) and initiating fall precautions (choice D) are important interventions, but administering thiamine takes precedence due to the risk of Wernicke's encephalopathy.

4. Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscular dystrophy. Which finding warrants immediate intervention by the nurse?

• A. Extremity muscle weakness.
• B. Bilateral eyelid drooping.
• C. Inability to swallow pills.
• D. Evidence of hypoventilation.

Correct answer: D

Rationale: The correct answer is D: Evidence of hypoventilation. In a client with muscular dystrophy and progressive kyphoscoliosis, hypoventilation indicates respiratory muscle weakness and can lead to life-threatening respiratory distress. Immediate intervention is crucial to prevent complications. Choices A, B, and C are incorrect because while extremity muscle weakness, bilateral eyelid drooping, and inability to swallow pills are concerning symptoms in muscular dystrophy, evidence of hypoventilation poses a more immediate threat to the client's respiratory status.

5. A male client is prescribed clozapine (Clozaril), an antipsychotic medication, for the management of schizophrenia. Which client history should the nurse report to the healthcare provider before administering the first dose of this medication?

• A. History of depression
• B. History of cardiac arrhythmia
• C. History of seizures
• D. History of diabetes mellitus

Correct answer: B

Rationale: The correct answer is B: History of cardiac arrhythmia. Clozapine can lead to severe cardiovascular problems, making it crucial to report any history of cardiac arrhythmia to the healthcare provider before administering the medication. Choices A, C, and D are less concerning in this context as they are not directly associated with potential serious complications related to clozapine use.

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