Nursing Elites

1. A nurse is assessing a client who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect?

• A. Constipation
• B. Absent deep-tendon reflexes
• C. Nausea and vomiting
• D. Tingling of the extremities

Correct answer: D

Rationale: Correct! A calcium level of 8.0 mg/dL indicates hypocalcemia. Hypocalcemia can lead to increased neuromuscular excitability, manifesting as tingling of the extremities. Choices A, B, and C are incorrect findings associated with other electrolyte imbalances or conditions and are not typically related to hypocalcemia. Constipation is commonly seen in hypokalemia, absent deep-tendon reflexes are associated with hypermagnesemia, and nausea and vomiting are more indicative of hypercalcemia.

2. During a presentation on basic first aid, a nurse educator evaluates a newly licensed home health nurse's understanding of heat stroke. Which symptom indicates the client has heat stroke?

• A. Hypotension
• B. Bradycardia
• C. Clammy skin
• D. Bradypnea

Correct answer: A

Rationale: The correct answer is A: Hypotension. Heat stroke can lead to hypotension, which is low blood pressure. This is a common symptom of heat stroke and requires immediate intervention. Bradycardia (slow heart rate), clammy skin, and bradypnea (slow breathing) are not typically associated with heat stroke. In heat stroke, the body's temperature regulation system fails, leading to a rapid rise in body temperature, which can cause various symptoms including hypotension.

3. What should the nurse do first when a client with a tracheostomy exhibits respiratory distress?

• A. Notify the provider
• B. Suction the tracheostomy
• C. Administer a bronchodilator
• D. Increase the oxygen flow rate

Correct answer: B

Rationale: The correct initial action when a client with a tracheostomy exhibits respiratory distress is to suction the tracheostomy. This helps to clear secretions and improve the client's ability to breathe. Notifying the provider (choice A) can cause a delay in immediate intervention. Administering a bronchodilator (choice C) may be necessary but is not the priority in this situation. Increasing the oxygen flow rate (choice D) can be helpful but should come after addressing the immediate need for suctioning to clear the airway.

4. What is the best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care?

• A. Instruct the client to rest completely and avoid all self-care tasks
• B. Encourage the client to gradually resume self-care tasks with frequent rest periods
• C. Assign assistive personnel to complete all self-care tasks
• D. Ask the client's family to assist with self-care tasks

Correct answer: B

Rationale: The best strategy for managing fatigue in a client who has had an acute myocardial infarction and is concerned about self-care is to encourage the client to gradually resume self-care tasks with frequent rest periods. This approach helps the client regain independence while managing fatigue effectively. Choice A is incorrect because complete rest without any self-care tasks may hinder recovery and independence. Choice C is not the best option as it does not promote the client's independence. Choice D, while involving family support, does not empower the client to regain self-care abilities.

5. A client with diabetes is experiencing hyperglycemia. What is the nurse's priority?

• A. Administer insulin
• B. Encourage the client to exercise to lower blood glucose
• C. Encourage the client to drink water
• D. Administer glucagon

Correct answer: A

Rationale: The correct answer is to administer insulin. In hyperglycemia, there is an excess of glucose in the blood, which needs to be lowered. Insulin is the primary medication used to lower blood glucose levels by facilitating the uptake of glucose into cells. Encouraging the client to exercise may further increase blood glucose levels due to the release of stress hormones, so it is not the priority. While staying hydrated is important, it will not directly address the high blood glucose levels seen in hyperglycemia. Glucagon is used to treat severe hypoglycemia, not hyperglycemia, so it is not the priority in this situation.

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