Nursing Elites

1. A client with diabetes is experiencing symptoms of hypoglycemia. What should the nurse administer first?

• A. 10 units of regular insulin subcutaneously
• B. 50 mL of 50% dextrose solution intravenously
• C. 1 mg of glucagon intramuscularly
• D. 15-20 grams of fast-acting carbohydrate orally

Correct answer: D

Rationale: The correct first intervention for a client experiencing hypoglycemia is administering 15-20 grams of fast-acting carbohydrate orally. If the client is conscious and able to swallow, providing quick-acting carbohydrates helps raise blood glucose levels rapidly and effectively. This approach is preferred over other options like administering insulin, dextrose solution intravenously, or glucagon, which are not the initial interventions for hypoglycemia.

2. A nurse is assessing a client for a suspected anaphylactic reaction following a CT scan with contrast media. For which of the following client findings should the nurse intervene first?

• A. Urticaria
• B. Stridor
• C. Vomiting
• D. Hypotension

Correct answer: B

Rationale:

3. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

• A. Raise the affected extremity above the level of the heart.
• B. Immobilize the affected extremity with a splint
• C. Apply ice to the bite area
• D. Apply a tourniquet to the affected extremity.

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

4. A healthcare professional is assessing a client who has a new onset of confusion. Which laboratory value should the professional check first?

• A. Blood glucose level
• B. Serum sodium level
• C. Serum calcium level
• D. Blood urea nitrogen (BUN)

Correct answer: A

Rationale: In a client presenting with a new onset of confusion, checking the blood glucose level first is crucial as hypoglycemia can cause confusion and is easily correctable. Addressing hypoglycemia promptly is essential to prevent further complications.

5. A client with asthma is assessed by a nurse and presents with bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply)

• A. Administer prescribed albuterol (Ventolin) inhaler.
• B. Assess the client for tracheal deviation.
• C. Administer oxygen to maintain saturations greater than 94%.
• D. Perform peak expiratory flow measurements.

Correct answer: C

Rationale: Suprasternal retraction during inhalation indicates the use of accessory muscles and difficulty in moving air due to airway narrowing, supported by bilateral wheezing and decreased pulse oxygen saturation. This client needs immediate intervention as their asthma is not responding to the medication. Administering oxygen to maintain saturations above 94% is crucial to ensure adequate oxygenation. While administering a rescue inhaler could also be necessary, oxygen therapy takes priority in this situation.

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