Nursing Elites

1. A client with type 1 diabetes mellitus reports feeling shaky and has a blood glucose level of 60 mg/dl. What action should the nurse take?

• A. Administer 15 grams of carbohydrate
• B. Administer a glucagon injection
• C. Provide a snack with protein
• D. Encourage the client to rest

Correct answer: A

Rationale: The correct action for a client with type 1 diabetes mellitus experiencing hypoglycemia with a blood glucose level of 60 mg/dl is to administer 15 grams of carbohydrate. This will help raise the blood glucose levels quickly. Administering a glucagon injection (Choice B) is usually reserved for severe hypoglycemia where the client is unconscious or unable to swallow. Providing a snack with protein (Choice C) is not the first-line treatment for hypoglycemia as protein takes longer to raise blood glucose levels. Encouraging the client to rest (Choice D) may be beneficial after administering the carbohydrate, but the priority is to raise the blood glucose levels promptly.

2. While teaching a group of adults about health promotion activities, a nurse identifies a behavior that poses the most significant risk factor for the development of skin cancer. Which behavior should the nurse address?

• A. Consuming a high-fat diet
• B. Using tanning beds
• C. Smoking cigarettes
• D. Drinking alcohol

Correct answer: B

Rationale: Using tanning beds is the most significant risk factor for developing skin cancer. Ultraviolet (UV) radiation from tanning beds damages the skin and increases the risk of skin cancer. Consuming a high-fat diet, smoking cigarettes, and drinking alcohol are unhealthy behaviors but are not directly linked to the development of skin cancer like UV exposure from tanning beds.

3. The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?

• A. Vastus lateralis
• B. Deltoid
• C. Ventrogluteal
• D. Dorsogluteal

Correct answer: A

Rationale: The vastus lateralis is the preferred site for IM injections in infants due to muscle development. In infants under 1 year old, the vastus lateralis muscle in the thigh is often used for IM injections due to its size and development. The deltoid muscle is typically used for adults, and the ventrogluteal and dorsogluteal sites are more commonly used for older children and adults. Therefore, the best choice for administering an IM injection to a 6-month-old child is the vastus lateralis.

4. A client with chronic renal failure is receiving peritoneal dialysis. The nurse notes that the client's dialysate output is less than the input and that the client's abdomen is distended. What action should the nurse take first?

• A. Turn the client from side to side
• B. Increase the dwell time of the dialysis
• C. Reposition the client
• D. Milk the catheter

Correct answer: A

Rationale: The correct first action for the nurse to take is turning the client from side to side. This helps to facilitate drainage in peritoneal dialysis. Turning the client can aid in redistributing the dialysate and promoting better drainage. Increasing the dwell time of the dialysis (choice B) may not address the immediate issue of inadequate drainage. Repositioning the client (choice C) might not be as effective as turning the client from side to side. Milking the catheter (choice D) is not recommended as it can lead to complications. In this situation, the priority is to facilitate drainage to address the distended abdomen.

5. Oxygen at liters/min per nasal cannula PRN difficult breathing is prescribed for a client with pneumonia. Which nursing intervention is effective in preventing oxygen toxicity?

• A. Avoiding the administration of high levels of oxygen for extended periods.
• B. Administering a sedative at bedtime to slow the client's respiratory rate.
• C. Removing the nasal cannula during the night to prevent oxygen buildup.
• D. Running oxygen through a hydration source prior to administration.

Correct answer: A

Rationale: The correct answer is A: Avoiding the administration of high levels of oxygen for extended periods. Oxygen toxicity can occur when high levels of oxygen are given for a prolonged period. It is important to monitor and adjust the oxygen levels as needed to prevent toxicity. Choice B is incorrect because administering a sedative to slow the respiratory rate does not directly prevent oxygen toxicity. Choice C is incorrect as removing the nasal cannula during the night can compromise the client's oxygenation. Choice D is incorrect as running oxygen through a hydration source does not prevent oxygen toxicity; instead, it may introduce risks associated with the hydration source.

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