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. When preparing to administer blood to a client, what is the most important action to ensure client safety during this procedure?

• A. Check the client’s blood type compatibility
• B. Monitor the client for signs of transfusion reaction
• C. Verify the correct client and blood product with another healthcare professional
• D. All of the above

Correct answer: D

Rationale: The most important action to ensure client safety during a blood transfusion is to implement multiple safety checks. Checking the client’s blood type compatibility is crucial as it helps prevent major transfusion reactions. Monitoring the client for signs of transfusion reaction is essential to detect any adverse reactions early. Verifying the correct client and blood product with another healthcare professional adds an extra layer of safety by ensuring the right blood is administered to the right patient. Choosing 'All of the above' (Option D) is the correct answer because each action plays a vital role in ensuring the safety and well-being of the client during a blood transfusion. Options A, B, and C are not exclusive; they complement each other to provide comprehensive safety measures.

3. A client with a severe headache is being assessed by a nurse. What should the nurse do first?

• A. Administer pain relief medication
• B. Check the client's blood pressure
• C. Assess for associated symptoms such as nausea or photophobia
• D. Offer a quiet environment

Correct answer: B

Rationale: When a client presents with a severe headache, the initial action should be to check their blood pressure. This step is crucial as it can help determine if the headache is related to hypertension or other cardiovascular issues. Administering pain relief medication should only be done after assessing the client's vital signs and confirming the cause of the headache. While assessing for associated symptoms like nausea or photophobia is important for a comprehensive evaluation, it should follow checking the blood pressure to address immediate concerns. Offering a quiet environment is indeed beneficial for the client's comfort, but it is not the priority when dealing with a severe headache.

4. The healthcare provider plans to assess a newborn and check the infant's Moro reflex. What is the healthcare provider evaluating?

• A. Neurological integrity
• B. Renal functioning
• C. Thermoregulation
• D. Respiratory adequacy

Correct answer: A

Rationale: The Moro reflex is an instinctive response observed in newborns, indicating their neurological integrity. This reflex is evaluated by eliciting a startle response in the infant, involving the sudden extension and abduction of the limbs, followed by their retraction. This assessment helps in determining the proper functioning of the infant's nervous system and brain. Choices B, C, and D are incorrect as they do not relate to the evaluation of the Moro reflex. Renal functioning pertains to kidney function, thermoregulation refers to temperature control, and respiratory adequacy involves assessing breathing and oxygenation levels, none of which are evaluated through the Moro reflex.

5. A healthcare provider is reviewing a client's medication list during a routine visit. Which action is most important to ensure medication safety?

• A. Ask the client about any allergies to medications
• B. Review the purposes of each medication
• C. Check for potential drug interactions
• D. All of the above

Correct answer: D

Rationale: A comprehensive review of allergies, medication purposes, and potential interactions is crucial for ensuring medication safety. Asking about allergies helps prevent adverse reactions, reviewing medication purposes ensures the correct use of each drug, and checking for potential drug interactions reduces the risk of harmful effects when medications interact. Choosing 'All of the above' is the correct answer because all three actions are essential steps to enhance medication safety. Options A, B, and C individually play vital roles in promoting medication safety, making option D the most appropriate choice.

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