Nursing Elites

1. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?

• A. Check the blood glucose level
• B. Administer insulin immediately
• C. Offer a high-protein snack
• D. Place the client in a supine position

Correct answer: A

Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.

2. A client with chronic heart failure is being discharged with a new prescription for furosemide. Which instruction should the nurse include in the discharge teaching?

• A. Increase your intake of potassium-rich foods.
• B. Restrict your fluid intake to 1 liter per day.
• C. Avoid salt substitutes containing potassium.
• D. Weigh yourself once a week.

Correct answer: A

Rationale: The correct answer is to instruct the client to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss due to increased urinary excretion. Potassium-rich foods can help prevent hypokalemia, a potential side effect of furosemide. Restricting fluid intake (choice B) may not be suitable for all patients with heart failure, and a general restriction of 1 liter per day is not typically recommended. Avoiding salt substitutes containing potassium (choice C) is not a priority teaching point in this scenario. Weighing oneself once a week (choice D) is important for monitoring fluid status, but increasing potassium-rich foods is more directly related to the potential side effects of furosemide.

3. A male client with heart failure calls the clinic and reports that he cannot put his shoes on because they are too tight. Which additional information should the nurse obtain?

• A. What time he took his medication?
• B. Has his weight changed in the last several days?
• C. Is he still able to tighten his belt buckle?
• D. How many hours he slept last night?

Correct answer: B

Rationale: The correct answer is B: 'Has his weight changed in the last several days?' Sudden weight gain can indicate fluid retention, which is a common symptom of worsening heart failure. The inability to put on tight shoes can be due to fluid retention leading to swelling in the feet and ankles. Choices A, C, and D do not directly address the potential fluid retention issue and are less relevant in this scenario.

4. Which type of lipoprotein is associated with decreasing the risk of atherosclerosis?

• A. High-density lipoprotein (HDL)
• B. Low-density lipoprotein (LDL)
• C. Very low-density lipoprotein (VLDL)
• D. Intermediate-density lipoprotein (IDL)

Correct answer: A

Rationale: The correct answer is High-density lipoprotein (HDL). HDL is known as 'good' cholesterol because it helps remove cholesterol from the arteries, reducing the risk of atherosclerosis. LDL (choice B) is considered 'bad' cholesterol as it can deposit cholesterol in the arteries, increasing the risk of atherosclerosis. VLDL (choice C) and IDL (choice D) are also associated with increased risk of atherosclerosis rather than decreasing it.

5. Ten hours following thrombolysis for an ST elevation myocardial infarction (STEMI), a client is receiving a lidocaine infusion for isolated runs of ventricular tachycardia. Which finding should the nurse document in the EMR as a therapeutic response to the lidocaine infusion?

• A. Stabilization of BP ranges
• B. Cessation of chest pain
• C. Reduced heart rate
• D. Decreased frequency of episodes of VT

Correct answer: D

Rationale: The correct answer is D. Decreased frequency of ventricular tachycardia (VT) episodes indicates that the lidocaine infusion is effectively managing the ventricular tachycardia. Stabilization of BP ranges (choice A) may not directly correlate with the therapeutic response to lidocaine for VT. Cessation of chest pain (choice B) may indicate pain relief but does not specifically address the effectiveness of lidocaine for VT. Reduced heart rate (choice C) is not a direct indicator of the response to lidocaine for managing VT.

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