Nursing Elites

1. A client is undergoing chemotherapy and is at risk for developing thrombocytopenia. What precaution should the nurse teach the client to minimize the risk of bleeding?

• A. Use a soft-bristled toothbrush.
• B. Engage in daily aerobic exercise.
• C. Take aspirin for headaches.
• D. Use an electric razor for shaving.

Correct answer: A

Rationale: Using a soft-bristled toothbrush is essential for clients at risk of thrombocytopenia to prevent gum bleeding, as their platelet counts may be low. Vigorous brushing with a hard-bristled toothbrush can injure the gums, leading to bleeding, which can be exacerbated in clients with low platelets. Therefore, advising the client to use a soft-bristled toothbrush is a crucial precaution to minimize the risk of bleeding.

2. A patient with type 1 diabetes is prescribed insulin glargine. What is the primary characteristic of this insulin?

• A. Rapid-acting
• B. Intermediate-acting
• C. Long-acting
• D. Short-acting

Correct answer: C

Rationale: Insulin glargine is classified as a long-acting insulin. It is designed to provide a consistent level of insulin over approximately 24 hours, helping to keep blood glucose levels stable throughout the day. This long duration of action makes it suitable for basal insulin replacement in patients with type 1 diabetes, providing a background level of insulin to mimic the body's natural release of insulin between meals and overnight.

3. The healthcare provider is assessing a client with Raynaud's phenomenon. Which finding should the healthcare provider expect?

• A. Thickened and hardened skin.
• B. Painless ulcers on the fingertips.
• C. Episodes of cyanosis and pallor in the fingers.
• D. Red, scaly patches on the hands.

Correct answer: C

Rationale: Raynaud's phenomenon is characterized by vasospasm, leading to episodes of cyanosis (bluish discoloration) and pallor (pale color) in the fingers or toes, often triggered by cold temperatures or stress. This occurs due to the reduced blood flow during vasospastic episodes, causing the discoloration. Choices A, B, and D are incorrect findings associated with other conditions and are not typical of Raynaud's phenomenon.

4. A client with a history of diabetes mellitus presents with confusion, sweating, and palpitations. What should the nurse do first?

• A. Check the client's blood glucose level.
• B. Administer 10 units of insulin.
• C. Give the client a high-protein snack.
• D. Measure the client's blood pressure.

Correct answer: A

Rationale: The correct first action for a client presenting with confusion, sweating, and palpitations, suggestive of hypoglycemia, is to check the client's blood glucose level. This step helps to confirm if the symptoms are due to low blood sugar levels and guides appropriate interventions. Administering insulin without knowing the current blood glucose level can be dangerous and is not recommended as the initial step. Offering a high-protein snack may be necessary after confirming hypoglycemia, but checking the blood glucose level takes precedence. Measuring blood pressure is not the priority in this situation; addressing hypoglycemia is the immediate concern.

5. The healthcare provider is caring for a client with Guillain-Barré syndrome. Which assessment finding requires the healthcare provider's immediate action?

• A. Loss of deep tendon reflexes.
• B. Ascending weakness.
• C. New onset of confusion.
• D. Decreased vital capacity.

Correct answer: D

Rationale: Decreased vital capacity is the most critical assessment finding in a client with Guillain-Barré syndrome as it indicates respiratory compromise. This requires immediate intervention to ensure adequate ventilation and prevent respiratory failure, a common complication of this syndrome. Monitoring and maintaining respiratory function are vital in these clients to prevent complications such as respiratory distress, hypoxia, and respiratory failure. Loss of deep tendon reflexes and ascending weakness are typical manifestations of Guillain-Barré syndrome but do not require immediate action compared to compromised respiratory function. New onset of confusion may be a concern but is not as immediately life-threatening as decreased vital capacity.

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