Nursing Elites

1. A client with Type 1 diabetes reports feeling shaky and lightheaded. The nurse checks the client's blood glucose level and it is 60 mg/dL. What action should the nurse take first?

• A. Give the client a glucagon injection
• B. Encourage the client to eat a high-protein snack
• C. Recheck the blood glucose level in 15 minutes
• D. Administer 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The correct answer is D: Administer 15 grams of a fast-acting carbohydrate. The first step in treating hypoglycemia is to quickly raise the client's blood sugar level. Fast-acting carbohydrates like glucose tablets or juice are essential for this purpose. Giving a glucagon injection is typically reserved for severe hypoglycemia when the client is unable to take anything by mouth. Encouraging the client to eat a high-protein snack is not appropriate for immediate treatment of hypoglycemia. Rechecking the blood glucose level in 15 minutes is important after administering the fast-acting carbohydrate to ensure that the blood sugar has returned to a safe level.

2. A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse?

• A. Pain radiates to the back
• B. Nausea and vomiting without relief
• C. Abdominal pain decreases when lying supine
• D. Abdominal pain is worse after eating

Correct answer: D

Rationale: The correct answer is D. In acute pancreatitis, abdominal pain typically worsens after eating due to the stimulation of the pancreas to release enzymes that irritate the inflamed tissues. Pain relief when lying supine is uncommon and usually exacerbates discomfort. While nausea and vomiting are common symptoms, they are not as indicative of changes in pain intensity. Pain radiating to the back is characteristic but does not specifically relate to exacerbation post-eating.

3. A client is admitted to isolation with active tuberculosis. What infection control measures should the nurse implement?

• A. Initiate protective environment precautions.
• B. Use droplet precautions only.
• C. Ensure a positive pressure environment in the room.
• D. Implement negative pressure and contact precautions.

Correct answer: D

Rationale: When caring for a client with active tuberculosis, it is crucial to implement negative pressure rooms and contact precautions to prevent the spread of infection. Choice A, initiating protective environment precautions, is incorrect as this is not the recommended approach for tuberculosis. Choice B, using droplet precautions only, is insufficient as tuberculosis requires additional precautions. Choice C, ensuring a positive pressure environment in the room, is incorrect because negative pressure rooms are necessary to contain airborne pathogens like tuberculosis. Therefore, the most appropriate measures include implementing negative pressure rooms and contact precautions.

4. A client receiving IV heparin reports abdominal pain and tarry stools. What is the nurse's priority action?

• A. Prepare to administer protamine sulfate.
• B. Continue the heparin infusion and notify the healthcare provider.
• C. Monitor the client's vital signs and assess abdominal pain.
• D. Administer a PRN dose of morphine sulfate.

Correct answer: A

Rationale: The correct answer is to prepare to administer protamine sulfate. Abdominal pain and tarry stools are indicative of gastrointestinal bleeding, a serious side effect of heparin therapy. Protamine sulfate is the antidote for heparin and is used to reverse its effects in cases of bleeding. Continuing the heparin infusion (Choice B) is not appropriate when the client is experiencing signs of bleeding. Monitoring vital signs and assessing abdominal pain (Choice C) is important but not the priority when immediate action is required to address potential bleeding. Administering morphine sulfate (Choice D) is not the priority in this situation; addressing the underlying cause of bleeding takes precedence.

5. Which strategy should the nurse implement when teaching a client with low literacy about a new diagnosis of hypertension?

• A. Provide a detailed handout with complex terms
• B. Use simple language and visual aids
• C. Encourage the client to research the diagnosis online
• D. Incorporate medical jargon to explain the condition

Correct answer: B

Rationale: The correct strategy for teaching a client with low literacy about a new diagnosis of hypertension is to use simple language and visual aids. This approach helps ensure better understanding of the diagnosis and treatment plan by making the information clear and accessible. Providing a detailed handout with complex terms (Choice A) would not be suitable as it may confuse the client further. Encouraging the client to research the diagnosis online (Choice C) could lead to misinformation and overwhelm the client with information they may not understand. Incorporating medical jargon to explain the condition (Choice D) would not be helpful for a client with low literacy as it may complicate rather than clarify the information.

Similar Questions