Nursing Elites

1. What is the primary cause of diabetic ketoacidosis (DKA)?

• A. Insulin deficiency
• B. Overhydration
• C. Excess carbohydrate intake
• D. Excess insulin

Correct answer: A

Rationale: The correct answer is A: Insulin deficiency. Diabetic ketoacidosis occurs due to a severe lack of insulin, causing the body to break down fat for energy, leading to the production of ketones and acidification of the blood. Option B, Overhydration, is incorrect as DKA is characterized by dehydration rather than overhydration. Option C, Excess carbohydrate intake, is incorrect because while high blood sugar levels can contribute to DKA, the primary cause is insulin deficiency. Option D, Excess insulin, is also incorrect as DKA is not caused by an excess of insulin but rather by a lack of it.

2. The nurse is providing care for a client with type 1 diabetes mellitus who is receiving NPH insulin. The nurse notices that the client's evening glucose levels are consistently above 260 mg/dl. What does this indicate?

• A. States that her feet are constantly cold and feel numb
• B. A wound on the ankle that starts to drain and becomes painful
• C. Consecutive evening serum glucose greater than 260 mg/dl
• D. Reports nausea in the morning but still able to eat breakfast

Correct answer: C

Rationale: High evening glucose levels suggest that the current insulin dosage may be inadequate to control the client's blood sugar levels effectively. This indicates poor glycemic control and the need for a possible adjustment in the insulin regimen. Option A describes symptoms of peripheral neuropathy, which are not directly related to the elevated glucose levels but may be a long-term complication of diabetes. Option B describes a wound infection, which is not directly related to the client's high glucose levels. Option D mentions morning nausea, which could be due to various causes and is not directly related to the high evening glucose levels.

3. A client is recovering from a below-the-knee amputation (BKA). The client reports phantom limb pain. What should the nurse include in the client’s care plan to manage this type of pain?

• A. Apply heat to the residual limb.
• B. Administer prescribed analgesics.
• C. Elevate the residual limb.
• D. Perform range-of-motion exercises.

Correct answer: B

Rationale: Phantom limb pain is a type of pain that feels like it's coming from a body part that's no longer there. It is essential to understand that phantom limb pain is real and should be managed appropriately. Administering prescribed analgesics is the most effective way to address this discomfort. Applying heat, elevating the residual limb, and performing range-of-motion exercises are not effective in managing phantom limb pain since the pain originates from the brain expecting sensory input from the missing limb, rather than being related to physical factors that heat, elevation, or exercises can address.

4. While caring for a client with a new tracheostomy, the nurse notices that the client is attempting to speak but is unable to. What should the nurse explain to the client regarding their inability to speak?

• A. Speaking is not possible because the tracheostomy tube blocks the vocal cords.
• B. The tracheostomy tube prevents air from reaching the vocal cords, making speech difficult.
• C. The client will regain the ability to speak once the tracheostomy tube is removed.
• D. The tracheostomy tube must be replaced with a speaking valve for the client to speak.

Correct answer: B

Rationale: The correct answer is B. The tracheostomy tube bypasses the vocal cords, preventing air from reaching them, which is necessary for speech. This makes speaking difficult but not impossible. Removing the tracheostomy tube does not automatically restore the ability to speak (choice C). While a speaking valve can be added later to allow speech, initially, the tracheostomy tube itself hinders air from reaching the vocal cords, making speech difficult (choice D is incorrect). Choice A is incorrect as the tracheostomy tube does not block the vocal cords directly; instead, it prevents air from reaching them.

5. Which of the following is a critical step in preventing ventilator-associated pneumonia (VAP)?

• A. Performing oral care with chlorhexidine
• B. Elevating the head of the bed to 30-45 degrees
• C. Administering prophylactic antibiotics
• D. Changing the ventilator circuit daily

Correct answer: B

Rationale: Elevating the head of the bed to 30-45 degrees is a critical step in preventing ventilator-associated pneumonia (VAP) because it helps reduce the risk of aspiration, which is a significant factor in the development of VAP. Elevating the head of the bed enhances pulmonary hygiene, decreases the risk of microaspiration, and promotes better lung function. Performing oral care with chlorhexidine is essential for oral hygiene but is not specifically aimed at preventing VAP. Administering prophylactic antibiotics without a clear indication can lead to antibiotic resistance and is not a recommended routine practice to prevent VAP. Changing the ventilator circuit daily is essential for infection control but is not the most critical step in preventing VAP.

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