Nursing Elites

1. A client with diabetes mellitus is admitted with hyperglycemia. What is the priority nursing action?

• A. Administer insulin as prescribed
• B. Encourage fluid intake
• C. Monitor blood glucose levels frequently
• D. Assess for signs of hypoglycemia

Correct answer: A

Rationale: Administering insulin is the priority nursing action for a client admitted with hyperglycemia due to diabetes mellitus. Insulin helps lower blood glucose levels and prevent further complications associated with hyperglycemia. Encouraging fluid intake is important but not the priority as insulin administration takes precedence to address the immediate hyperglycemic state. Monitoring blood glucose levels frequently is essential but comes after administering insulin to ensure the treatment's effectiveness. Assessing for signs of hypoglycemia is incorrect as the client is admitted with hyperglycemia, which requires raising blood glucose levels, not lowering them further.

2. A client with a diagnosis of myocardial infarction (MI) is prescribed nitroglycerin. What is the primary action of this medication?

• A. Increases heart rate
• B. Lowers blood pressure
• C. Dilates coronary arteries
• D. Reduces myocardial oxygen demand

Correct answer: C

Rationale: The correct answer is C: Nitroglycerin dilates coronary arteries, improving blood flow to the heart muscle. This helps increase oxygen supply to the heart tissue. Option A, 'Increases heart rate,' is incorrect because nitroglycerin does not directly affect heart rate. Option B, 'Lowers blood pressure,' is also incorrect as while nitroglycerin can lower blood pressure, its primary action in the context of MI is related to coronary artery dilation. Option D, 'Reduces myocardial oxygen demand,' is not the primary action of nitroglycerin in the treatment of myocardial infarction; its main action is to increase oxygen supply by dilating coronary arteries.

3. To assess pedal pulses, which arterial sites should the nurse palpate? (Select all that apply)

• A. Posterior tibial artery
• B. Radial artery
• C. External iliac artery
• D. Dorsalis pedis artery

Correct answer: D

Rationale: The correct answer is D: Dorsalis pedis artery. When assessing pedal pulses, the nurse should palpate the dorsalis pedis artery and the posterior tibial artery. The radial artery is located in the wrist and is not a site for assessing pedal pulses. The external iliac artery is not a correct site for assessing pedal pulses in the lower extremities, making it the correct answer.

4. What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?

• A. Take the medication with food
• B. Avoid foods high in tyramine
• C. Report any thoughts of self-harm immediately
• D. Expect to see improvement within 24 hours

Correct answer: C

Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.

5. The client with heart failure is prescribed furosemide (Lasix). What should the nurse include in the teaching plan?

• A. Increase potassium-rich foods in the diet
• B. Avoid foods high in sodium
• C. Monitor fluid intake and adjust as needed
• D. Take the medication in the morning

Correct answer: A

Rationale: The correct answer is to instruct the client to increase potassium-rich foods in the diet. Furosemide is a loop diuretic that can cause potassium loss as a side effect. By increasing potassium-rich foods, the client can help prevent hypokalemia, a potential complication of furosemide therapy. Choice B is incorrect because while limiting sodium intake is generally advisable for heart failure, it is not directly related to furosemide use. Choice C is incorrect because fluid intake should be monitored and adjusted based on the individual's condition, but setting a specific limit of 1 liter per day is not a standard recommendation. Choice D is incorrect because furosemide is usually taken in the morning to prevent disturbances in sleep due to increased urination during the night.

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