Nursing Elites

1. A client has a blood glucose level of 70 mg/dl and reports feeling shaky and weak. What is the best initial action by the nurse?

• A. Obtain a fingerstick glucose reading
• B. Administer 15 grams of a fast-acting carbohydrate
• C. Perform a quick assessment of the client’s neuro status
• D. Provide a glass of milk and monitor the client’s symptoms

Correct answer: B

Rationale: Administering 15 grams of a fast-acting carbohydrate is the best initial action to address hypoglycemia symptoms promptly by raising blood glucose levels. This intervention is crucial to prevent further deterioration in the client's condition. Obtaining a fingerstick glucose reading is important but may delay treatment. Performing a quick assessment of the client's neuro status is secondary to addressing the immediate low blood glucose levels. Providing a glass of milk is not the recommended first-line treatment for hypoglycemia; fast-acting carbohydrates are preferred to rapidly increase blood sugar levels.

2. A female client reports she has not had a bowel movement for 3 days, but now is defecating frequent small amounts of liquid stool. Which action should the nurse implement?

• A. Digitally check the client for a fecal impaction
• B. Increase fluid intake to promote bowel regularity
• C. Provide a high-fiber diet to facilitate bowel movements
• D. Administer a stool softener

Correct answer: A

Rationale: The correct answer is A: Digitally check the client for a fecal impaction. Small, frequent liquid stools following constipation may indicate a fecal impaction. This intervention is crucial to assess and address a potential impaction promptly. Choices B, increasing fluid intake, and C, providing a high-fiber diet, may help with bowel regularity in general cases, but they don't directly address the urgent concern of a possible impaction. Choice D, administering a stool softener, is not appropriate as the first action when a fecal impaction is suspected; it could worsen the condition by causing further liquid stool output without addressing the impaction.

3. When gathering subjective data from a client, what intervention should the nurse implement first?

• A. Listen attentively
• B. Establish rapport
• C. List problems
• D. Clarify inferences

Correct answer: B

Rationale: Establishing rapport is the initial step the nurse should take when gathering subjective data from a client. Building trust and a good relationship with the client creates an environment where the client feels comfortable sharing accurate and honest information. Listening attentively is important but should come after rapport is established to enhance active listening. Listing problems and clarifying inferences are actions that occur later in the assessment process, after the nurse has established a good rapport and obtained a comprehensive understanding of the client's perspective. Therefore, option B is the correct answer.

4. When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour? (Enter numeric value only. If rounding is required, round to the nearest whole number. Click on each chart tab for additional information. Please be sure to scroll to the bottom right corner of each tab to view all information contained in the client’s medical record.)

• A. 5
• B. 10
• C. 15
• D. 20

Correct answer: A

Rationale: The correct infusion rate can be calculated based on the information provided in the chart. With contractions occurring every 2-3 minutes, the recommended infusion rate is 5 ml/hr. This rate ensures proper hydration and medication delivery to support the client during labor. Choices B, C, and D are incorrect as they do not align with the calculated rate based on the contractions frequency and the client's needs.

5. The healthcare provider is completing a head-to-toe assessment for a client admitted for observation after falling out of a tree. Which finding warrants immediate intervention by the healthcare provider?

• A. Sluggish pupillary response to light
• B. Clear fluid leaking from the nose
• C. Complaint of severe headache
• D. Periorbital ecchymosis of the right eye

Correct answer: B

Rationale: Clear fluid leaking from the nose is concerning for cerebrospinal fluid leakage, which is a medical emergency requiring immediate intervention. Sluggish pupillary response to light may indicate neurological issues but is not as urgent as CSF leakage. Complaint of severe headache is important but not as critical as the possibility of CSF leakage. Periorbital ecchymosis of the right eye could be indicative of trauma but does not pose an immediate threat to the patient's life.

Similar Questions