Nursing Elites

1. A nurse is administering insulin to a patient after misreading their glucose as 210 mg/dL instead of 120 mg/dL. What should the nurse monitor for?

• A. Monitor for hypoglycemia
• B. Monitor for hyperkalemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: A

Rationale: The correct answer is to monitor for hypoglycemia. Insulin administration based on a misread glucose level can lead to hypoglycemia due to the unnecessary lowering of blood sugar levels. Monitoring for hypoglycemia involves assessing the patient's blood glucose levels frequently, observing for signs and symptoms such as shakiness, confusion, sweating, and administering glucose if hypoglycemia occurs. Choice B, monitoring for hyperkalemia, is incorrect as insulin administration typically lowers potassium levels. Choice C, administering glucose IV, is not the immediate action needed as the patient could potentially develop hypoglycemia from the excess insulin. Choice D, documenting the incident, is important but not the immediate priority when dealing with a potential hypoglycemic event.

2. What should be done if a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the enema solution container
• B. Stop the procedure and remove the tubing
• C. Continue the enema at a slower rate
• D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the appropriate action is to lower the height of the enema solution container. This adjustment helps alleviate the cramping by reducing the pressure of the solution entering the colon. Stopping the procedure and removing the tubing (Choice B) is not necessary unless there are other complications. Continuing the enema at a slower rate (Choice C) may not address the immediate discomfort caused by cramping. Increasing the flow of the enema solution (Choice D) can exacerbate the cramping and should be avoided.

3. A client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

• A. Lie on your left side.
• B. Lie on your right side.
• C. Increase your fluid intake.
• D. Decrease your fluid intake.

Correct answer: B

Rationale: After a liver biopsy, the nurse should instruct the client to lie on the right side. This position helps apply pressure to the biopsy site, promoting hemostasis and reducing the risk of bleeding. Lying on the left side may not provide adequate pressure to the site. Increasing fluid intake is generally beneficial to prevent dehydration and aid in the recovery process, whereas decreasing fluid intake could lead to dehydration and possible complications. Therefore, the correct instruction is to lie on the right side.

4. What does continuous bubbling in the water seal chamber of a chest tube indicate?

• A. An air leak
• B. Drainage in the chest tube
• C. A blocked chest tube
• D. Normal chest tube function

Correct answer: A

Rationale: Continuous bubbling in the water seal chamber of a chest tube indicates an air leak. This signifies that air is escaping from the patient's pleural space into the chest tube system rather than being evacuated properly. An air leak can lead to lung collapse or pneumothorax and requires immediate attention. Therefore, choice A is the correct answer. Choices B, C, and D are incorrect because continuous bubbling does not indicate normal chest tube function, drainage in the chest tube, or a blocked chest tube.

5. A nurse at a provider's office is interviewing a client who has multiple sclerosis and has been taking dantrolene for several months. Which of the following client statements should the nurse identify as an indication that the medication is effective?

• A. I don't have muscle spasms as frequently.
• B. I haven't gotten any colds, even though it is flu season.
• C. I feel like my nerve pain has improved.
• D. It is easier to urinate now.

Correct answer: A

Rationale: The correct answer is A: 'I don't have muscle spasms as frequently.' Dantrolene is a medication that relaxes skeletal muscles and is commonly prescribed to treat muscle spasms in clients with multiple sclerosis. Therefore, a reduction in muscle spasms frequency would be an indication of the medication's effectiveness. Choices B, C, and D are incorrect because dantrolene is not indicated for preventing colds, improving nerve pain, or easing urination. The focus should be on the medication's intended purpose, which is to address muscle spasms in clients with multiple sclerosis.

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