Nursing Elites

1. A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dl and is unresponsive. Which intervention should the nurse implement first?

• A. Administer 50% dextrose IV push.
• B. Administer insulin as prescribed.
• C. Monitor the client's urine output.
• D. Obtain a blood glucose level.

Correct answer: A

Rationale: Administering 50% dextrose IV push is the first priority in treating a blood glucose level of 600 mg/dl in a client who is unresponsive due to hyperglycemia. This intervention is crucial to rapidly raise the client's blood glucose levels and address the emergency situation. Administering insulin (Choice B) would further lower the blood glucose level, worsening the client's condition. Monitoring urine output (Choice C) and obtaining a blood glucose level (Choice D) are important assessments but are secondary to the immediate need to address the high blood glucose levels causing the client's unresponsiveness.

2. A 59-year-old male client comes to the clinic and reports his concern over a lump that 'just popped up on my neck about a week ago.' In performing an examination of the lump, the nurse palpates a large, nontender, hardened left subclavian lymph node. There is no overlying tissue inflammation. What do these findings suggest?

• A. Malignancy
• B. Infection
• C. Benign cyst
• D. Lymphadenitis

Correct answer: A

Rationale: The correct answer is A: Malignancy. A large, non-tender, hardened lymph node is a typical sign of malignancy and warrants further investigation. Choice B (Infection) is incorrect because typically in infections, lymph nodes are tender and may show signs of inflammation. Choice C (Benign cyst) is incorrect as a benign cyst would usually present as a soft, mobile lump. Choice D (Lymphadenitis) is incorrect as lymphadenitis usually presents with tender and enlarged lymph nodes due to inflammation.

3. A client with a history of rheumatoid arthritis is prescribed prednisone. Which assessment finding requires immediate intervention?

• A. Increased joint pain
• B. Weight gain of 2 pounds in 24 hours
• C. Blood glucose level of 150 mg/dl
• D. Fever of 100.4°F

Correct answer: B

Rationale: The correct answer is B. Weight gain of 2 pounds in 24 hours is concerning in a client with rheumatoid arthritis on prednisone as it may indicate fluid retention or worsening heart failure. Increased joint pain, blood glucose level of 150 mg/dl, and fever of 100.4°F are important assessments but do not require immediate intervention compared to the potential severity of rapid weight gain.

4. The nurse is caring for a client following a myelogram. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Complaint of headaches and stiff neck.
• B. Complaint of dizziness and nausea.
• C. Increased pain at the puncture site.
• D. Mild redness around the puncture site.

Correct answer: A

Rationale: The correct answer is A: Complaint of headaches and stiff neck. Headaches and stiff neck following a myelogram may indicate a cerebrospinal fluid (CSF) leak or other complications that require prompt medical attention. Reporting this finding immediately is crucial to prevent further complications. Choices B, C, and D are incorrect because while they may warrant monitoring and intervention, they are not as indicative of a potentially serious complication as the symptoms described in choice A.

5. A client with a history of severe rheumatoid arthritis is receiving a corticosteroid. Which assessment finding should the nurse report to the healthcare provider immediately?

• A. Blood glucose level of 180 mg/dL
• B. Weight gain of 2 pounds in 24 hours
• C. Blood pressure of 140/90 mmHg
• D. Increased joint pain

Correct answer: C

Rationale: Elevated blood pressure (140/90 mmHg) is a significant finding that the nurse should report immediately. Hypertension can be a severe side effect of corticosteroid therapy, especially in clients with preexisting conditions like rheumatoid arthritis. It requires prompt intervention to prevent complications such as cardiovascular events. The other options, while important to monitor, are not as critical as elevated blood pressure in this context. A blood glucose level of 180 mg/dL may indicate hyperglycemia, weight gain could be due to fluid retention, and increased joint pain is expected in a client with severe rheumatoid arthritis.

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