Nursing Elites

1. 4 hours after administration of 20U of regular insulin, the client becomes shaky and diaphoretic. What action should the nurse take?

• A. Encourage the client to eat crackers and milk
• B. Administer a PRN dose of 10U of regular insulin
• C. Give the client crackers and milk
• D. Record the client's reaction in the diabetic flow sheet

Correct answer: C

Rationale: The correct action for the nurse to take when a client becomes shaky and diaphoretic after insulin administration, indicating hypoglycemia, is to provide the client with carbohydrates like crackers and milk. Carbohydrates help raise blood glucose levels quickly. Encouraging the client to eat crackers and milk (Choice A) is the appropriate immediate action to address the hypoglycemia. Administering more insulin (Choice B) would worsen hypoglycemia, and recording the reaction (Choice D) is important but not the immediate action needed to treat the hypoglycemia.

2. A client with a leg fracture reports increased pain and swelling. What should the nurse suspect?

• A. Compartment syndrome
• B. Deep vein thrombosis
• C. Wound infection
• D. All of the above

Correct answer: A

Rationale: Increased pain and swelling in a fracture could indicate compartment syndrome, a serious condition requiring urgent care. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to compromised blood flow and potential tissue damage. Deep vein thrombosis is less likely in this scenario as the symptoms are more indicative of compartment syndrome. Wound infection would typically present with localized signs of infection at the wound site, such as redness, warmth, and purulent drainage, rather than diffuse pain and swelling.

3. A client with hypothyroidism is being treated with levothyroxine (Synthroid). What is the most important information for the nurse to provide to the client?

• A. Take the medication on an empty stomach
• B. Monitor for signs of hyperthyroidism
• C. Expect to see results within a week
• D. Avoid exposure to sunlight

Correct answer: B

Rationale: The most important information for the nurse to provide to a client with hypothyroidism being treated with levothyroxine is to monitor for signs of hyperthyroidism. Too much levothyroxine can lead to symptoms of hyperthyroidism, indicating an overdose. Choice A is incorrect as levothyroxine is usually taken on an empty stomach to ensure optimal absorption. Choice C is inaccurate as it may take weeks to months to see the full effects of levothyroxine therapy due to the need for dosage adjustments. Choice D is unrelated to levothyroxine therapy and is not a crucial concern for this specific medication.

4. When taking blood pressure at the brachial artery, the nurse should place the client's arm in which position?

• A. Slightly above the level of the heart
• B. At the level of the heart
• C. At a level of comfort for the client
• D. Below the level of the heart

Correct answer: B

Rationale: When taking blood pressure at the brachial artery, it is crucial to place the client's arm at the level of the heart to ensure accurate measurement. Placing the arm above or below the heart level can lead to incorrect readings. Option A, placing the arm slightly above the heart level, would result in falsely lower blood pressure readings as gravity would assist in a lower value. Option C, placing the arm at a level of comfort for the client, may not align with the standardized technique required for accurate blood pressure assessment. Option D, placing the arm below the level of the heart, would likely yield falsely higher blood pressure readings due to increased hydrostatic pressure pushing the blood against gravity.

5. What is the most important aspect of colostomy care to teach the client?

• A. Change the colostomy bag only when necessary
• B. Eat a low-residue diet
• C. Assess the stoma for color and swelling
• D. Irrigate the colostomy only if advised by a healthcare provider

Correct answer: C

Rationale: The most important aspect of colostomy care to teach the client is to assess the stoma for color and swelling. This is crucial as it ensures early detection of complications such as ischemia or infection. Changing the colostomy bag only when necessary is more appropriate than doing it daily, as it prevents unnecessary changes that may irritate the skin. While eating a low-residue diet is beneficial, it is not the most crucial aspect to teach. Irrigating the colostomy should only be done if advised by a healthcare provider, as it is not a routine procedure for all clients with a colostomy.

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