Nursing Elites

1. What are the complications of untreated Type 1 diabetes?

• A. Diabetic ketoacidosis and retinopathy
• B. Hypoglycemia and neuropathy
• C. Hypotension and kidney failure
• D. Infection and fluid overload

Correct answer: A

Rationale: Diabetic ketoacidosis and retinopathy are indeed common complications of untreated Type 1 diabetes. Diabetic ketoacidosis occurs when the body starts breaking down fat for fuel, leading to a dangerous buildup of ketones in the blood. Retinopathy refers to damage to the blood vessels of the retina due to high blood sugar levels over time. The other choices, hypoglycemia and neuropathy (choice B), hypotension and kidney failure (choice C), and infection and fluid overload (choice D) are not typically the primary complications associated with untreated Type 1 diabetes.

2. Which of the following actions should the nurse take for a client who has been diagnosed with dementia and is at risk for falls?

• A. Maintain the client's bed in the lowest position
• B. Use a bed exit alarm system
• C. Assist the client with ambulation every hour
• D. Raise all 4 side rails for safety

Correct answer: B

Rationale: The correct answer is B: "Use a bed exit alarm system." For a client with dementia at risk for falls, a bed exit alarm system is beneficial as it alerts staff when the client is trying to get up, helping to reduce fall risks. Choice A, maintaining the client's bed in the lowest position, may not prevent falls as effectively as an alarm system. Choice C, assisting the client with ambulation every hour, may not be feasible and could disrupt the client's rest. Choice D, raising all 4 side rails for safety, can lead to restraint issues and is not recommended as a routine fall prevention measure.

3. Which is the correct method for teaching a client to use a cane when they have left-leg weakness?

• A. Use the cane on the weaker side of the body
• B. Advance the cane and the strong leg together
• C. Maintain two points of support on the floor at all times
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: C

Rationale: The correct method for teaching a client to use a cane when they have left-leg weakness is to maintain two points of support on the floor at all times. This approach ensures stability and helps the client maintain balance while using the cane. Choice A is incorrect because the cane should be used on the stronger side of the body to provide additional support. Choice B is incorrect as advancing the cane and the strong leg together may compromise stability. Choice D is incorrect as advancing the cane too far with each step can lead to imbalance and falls.

4. A nurse is assessing a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Elevated blood glucose.
• B. Decreased urine output.
• C. Dependent edema.
• D. Jaundice.

Correct answer: C

Rationale: The correct answer is C: Dependent edema. In right-sided heart failure, the heart is unable to effectively pump blood to the lungs for oxygenation, leading to fluid accumulation in the systemic circulation. This fluid backs up in the venous system, causing increased pressure in the veins of the body, resulting in dependent edema, usually starting in the lower extremities. Elevated blood glucose (choice A) is not directly related to right-sided heart failure. Decreased urine output (choice B) may occur in conditions like acute kidney injury but is not a specific finding of right-sided heart failure. Jaundice (choice D) is more commonly associated with liver dysfunction, not typically seen in right-sided heart failure.

5. A nurse is caring for a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: Performing a fundal massage is the priority action in a postpartum client experiencing excessive lochia discharge. Fundal massage helps prevent postpartum hemorrhage by ensuring the uterus contracts effectively. Administering pain medication, checking the baby's heart rate, and applying an ice pack are not the initial interventions needed to address excessive lochia discharge.

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