Nursing Elites

1. What are the complications of diabetic ketoacidosis?

• A. Electrolyte imbalance and dehydration
• B. Hypoglycemia and increased urination
• C. Kidney failure and respiratory distress
• D. Liver failure and hypertension

Correct answer: A

Rationale: The correct answer is A: Electrolyte imbalance and dehydration. Diabetic ketoacidosis can lead to imbalances in electrolytes such as potassium, sodium, and chloride, as well as dehydration due to excess urination and vomiting. These complications should be managed promptly with appropriate fluids and insulin. Choices B, C, and D are incorrect. Hypoglycemia and increased urination are not typical complications of diabetic ketoacidosis; kidney failure and respiratory distress may occur in severe cases but are not the primary complications. Liver failure and hypertension are not directly associated with diabetic ketoacidosis.

2. A charge nurse in a long-term care facility notices an assistive personnel's (AP) repeated failure to provide oral care for clients. Which of the following actions should the charge nurse take?

• A. Ignore the behavior
• B. Reassign the AP
• C. Report the behavior to the manager
• D. Discuss this behavior with the AP while reinforcing expectations

Correct answer: D

Rationale: When a charge nurse observes repeated failure in a staff member's performance, it is essential to address the issue directly. Choice D is the correct answer as it involves discussing the behavior with the assistive personnel (AP) while reinforcing expectations. This approach helps in clarifying the expected standards, setting accountability, and providing an opportunity for improvement. Choices A, B, and C are incorrect. Ignoring the behavior (Choice A) does not address the problem and can lead to continued substandard care. Reassigning the AP (Choice B) may not solve the issue and can potentially transfer the problem to another area. Reporting the behavior to the manager (Choice C) without directly addressing it with the AP first may not promote a constructive approach to resolving the issue.

3. A nurse is performing vision testing for a client following a head injury. Which of the following findings should the nurse identify as a problem with pupil accommodation?

• A. Pupils constrict when shifting gaze from near to far
• B. Pupils constrict when shifting gaze from far to near
• C. Lack of change in pupil size when shifting gaze from near to far
• D. Lack of change in pupil size when shifting gaze from far to near

Correct answer: D

Rationale: Pupil accommodation problems are indicated by the lack of change in size when shifting gaze from far to near. The correct answer is D because in pupil accommodation, the pupils should constrict when shifting gaze from far to near in order to adjust for near vision. Choices A and B describe normal responses of pupil constriction when shifting gaze, which do not indicate a problem. Choice C is incorrect as it describes a normal response of pupil size change when shifting gaze from near to far.

4. A client is experiencing difficulty voiding following the removal of an indwelling catheter. What action should the nurse take to assist the client?

• A. Assess for bladder distention after 4 hours
• B. Pour warm water over the perineum
• C. Restrict the client's oral fluid intake
• D. Restrict movement for at least 12 hours

Correct answer: B

Rationale: The correct action for the nurse to assist the client who is experiencing difficulty voiding after the removal of an indwelling catheter is to pour warm water over the perineum. This technique can help stimulate urination by promoting relaxation of the perineal muscles and improving blood flow to the area. Assessing for bladder distention after 4 hours (Choice A) is important but not the immediate intervention needed to assist the client in voiding. Restricting the client's oral fluid intake (Choice C) can exacerbate the issue by reducing urine production. Restricting movement for at least 12 hours (Choice D) is unnecessary and may lead to discomfort and other complications.

5. What is the nurse's priority when caring for a client with a tracheostomy who is showing signs of respiratory distress?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Notify the physician immediately
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy. When a client with a tracheostomy is experiencing respiratory distress, the priority intervention is to clear the airway by suctioning the tracheostomy to remove secretions that may be obstructing the air passage. Administering a bronchodilator (Choice A) may be considered if bronchospasm is present, but the immediate focus should be on clearing the airway. Notifying the physician (Choice C) is important but should not delay the immediate intervention of suctioning. Increasing the oxygen flow rate (Choice D) may provide temporary relief, but addressing the root cause of the distress by suctioning is the priority.

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