Nursing Elites

1. A nurse is assessing a client who has a blood glucose level of 250 mg/dL. Which of the following clinical manifestations is associated with this finding?

• A. Confusion
• B. Thirst
• C. Diaphoresis
• D. Shakiness

Correct answer: B

Rationale: Corrected Detailed Rationale: A blood glucose level of 250 mg/dL indicates hyperglycemia. Thirst (polydipsia) is a common clinical manifestation associated with hyperglycemia. The body tries to compensate for the high blood sugar by increasing fluid intake. Confusion (choice A) is more commonly associated with hypoglycemia, not hyperglycemia. Diaphoresis (choice C) and shakiness (choice D) are typical manifestations of hypoglycemia, not hyperglycemia. Therefore, the correct answer is increased thirst (polydipsia) in response to the elevated blood glucose level.

2. A nurse is teaching a client about the use of gabapentin. Which of the following should be included?

• A. It can cause drowsiness
• B. It has no side effects
• C. It is a pain reliever
• D. It can be taken with food

Correct answer: A

Rationale: The correct answer is A: 'It can cause drowsiness.' Gabapentin is known to cause drowsiness, and clients should be warned about this side effect. Choice B is incorrect because gabapentin, like any medication, can have side effects. Choice C is incorrect because although gabapentin is used for pain management, it is not classified as a pain reliever. Choice D is incorrect because gabapentin should be taken as prescribed by the healthcare provider, and specific instructions regarding food intake should be provided based on individual needs.

3. During triage following a mass casualty event, which client should be prioritized?

• A. A client with massive head trauma
• B. A client with full-thickness burns to the face and trunk
• C. A client showing signs of hypovolemic shock
• D. A client with an open fracture of the lower extremity

Correct answer: C

Rationale: During triage after a mass casualty event, the client showing signs of hypovolemic shock should be prioritized. Hypovolemic shock is a life-threatening condition that requires immediate attention to restore circulation and prevent death. While clients with head trauma, burns, and fractures also need urgent care, hypovolemic shock poses an immediate threat to life and must be addressed first to stabilize the client's condition.

4. A healthcare provider is reviewing the health history of an older adult who has a hip fracture. The healthcare provider should identify what as a risk factor for developing pressure injuries?

• A. Advanced age
• B. Urinary incontinence
• C. Regular skin assessments
• D. Adequate hydration

Correct answer: B

Rationale: Urinary incontinence is a significant risk factor for skin breakdown and pressure injuries. It can lead to prolonged skin exposure to moisture and irritants, increasing the susceptibility to pressure injuries. Advanced age (Choice A) is a risk factor due to changes in skin integrity and decreased tissue viability, but it is not as direct a risk factor as urinary incontinence. Regular skin assessments (Choice C) are important for early detection and prevention but are not a risk factor themselves. Adequate hydration (Choice D) is essential for overall skin health but is not a direct risk factor for pressure injuries.

5. A nurse is giving discharge instructions to a client who has a new ileostomy. The nurse should recognize that the teaching has been effective when the client states:

• A. I will make sure my medications are enteric-coated
• B. My stoma will drain liquid continuously
• C. I will change my pouch system every two weeks
• D. My stoma size will stay the same after it heals

Correct answer: B

Rationale: The correct answer is B. When a client with an ileostomy states that their stoma will drain liquid continuously, it indicates an understanding of the expected outcome. In an ileostomy, the stoma continuously drains liquid stool as it bypasses the large intestine where water is absorbed. Choices A, C, and D are incorrect because ensuring medications are enteric-coated, changing the pouch system every two weeks, and expecting the stoma size to remain the same after healing are not accurate statements related to an ileostomy.

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