Nursing Elites

1. A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?

• A. Administer insulin as prescribed
• B. Provide a carbohydrate-controlled snack
• C. Encourage physical activity
• D. Recheck the blood sugar

Correct answer: A

Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.

2. The nurse is caring for a client postoperatively following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?

• A. Keep the client in a low Fowler's position
• B. Maintain hip abduction with pillows
• C. Encourage early ambulation
• D. Place the client in a prone position

Correct answer: B

Rationale: Maintaining hip abduction with pillows is crucial in preventing dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and reduces the risk of the prosthesis becoming displaced. Choices A, C, and D are not as effective in preventing dislocation. Keeping the client in a low Fowler's position does not provide the necessary hip support. While early ambulation is important for circulation and preventing complications, maintaining hip abduction is more specific to preventing prosthesis dislocation. Placing the client in a prone position can increase the risk of hip prosthesis dislocation due to the extreme positioning.

3. What is the primary purpose of a chest tube in a client's care?

• A. To drain air and fluid from the pleural space
• B. To prevent infection in the thoracic cavity
• C. To assist with lung expansion
• D. To monitor intrathoracic pressure

Correct answer: A

Rationale: The correct answer is A: To drain air and fluid from the pleural space. A chest tube is primarily used to remove accumulated air or fluid in the pleural space, preventing lung collapse or compromise of lung function. This intervention aims to re-expand the lung and enhance respiratory function. Choice B is incorrect because preventing infection is not the primary purpose of a chest tube. Choice C is incorrect as lung expansion is a result of draining the pleural space, not the primary goal. Choice D is incorrect as monitoring intrathoracic pressure is not the main objective of a chest tube insertion.

4. The nurse plans to evaluate the effectiveness of several drugs administered by different routes. Arrange the routes of administration from fastest to slowest rate of absorption. 1. Intravenous 2. Sublingual 3. Intramuscular 4. Subcutaneous

• A. 1,2,3,4
• B. 4,3,2,1
• C. 2,4,3,1
• D. 3,4,1,2

Correct answer: A

Rationale: The correct order of routes of administration from fastest to slowest rate of absorption is 1. Intravenous, 2. Sublingual, 3. Intramuscular, 4. Subcutaneous. Intravenous administration provides the fastest absorption as the drug is directly injected into the bloodstream. Sublingual administration allows for rapid absorption through the mucous membranes under the tongue. Intramuscular administration has a slower absorption rate as the drug is injected into the muscle tissue. Subcutaneous administration is the slowest as the drug is injected into the fatty tissue under the skin, leading to a slower absorption compared to the other routes.

5. A client with a diagnosis of pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed.
• B. Encourage increased fluid intake.
• C. Perform chest physiotherapy.
• D. Provide humidified oxygen.

Correct answer: B

Rationale: Encouraging increased fluid intake is the appropriate intervention to assist the client with pneumonia who is having difficulty expectorating thick secretions. Adequate hydration helps to thin the secretions, making them easier to cough up. Administering antibiotics (Choice A) is important for treating the infection itself but does not directly address the thick secretions. Chest physiotherapy (Choice C) may be beneficial in some cases but is not the initial intervention for thick secretions. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

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