Nursing Elites

1. A nurse is assessing a client who has a sodium level of 125 mEq/L. Which of the following findings should the nurse expect?

• A. Increased appetite
• B. Dry mucous membranes
• C. Hypotension
• D. Hyperreflexia

Correct answer: C

Rationale: A sodium level of 125 mEq/L indicates hyponatremia, which can lead to hypotension. Hyponatremia is associated with signs such as confusion and weakness, rather than increased appetite, dry mucous membranes, or hyperreflexia. Therefore, the nurse should expect hypotension as a finding in a client with a sodium level of 125 mEq/L.

2. A client has had a nasogastric tube in place for 2 days. Which of the following findings indicates that the client has developed an adverse effect?

• A. Dry mucous membranes
• B. Polyuria
• C. Epistaxis
• D. Diarrhea

Correct answer: C

Rationale: The correct answer is C, 'Epistaxis.' Epistaxis (nosebleed) is a common adverse effect of prolonged nasogastric tube insertion due to irritation of the nasal mucosa. Dry mucous membranes (choice A) may indicate dehydration but are not a direct adverse effect of nasogastric tube insertion. Polyuria (choice B) is excessive urination and is not typically associated with nasogastric tube insertion. Diarrhea (choice D) is also not a common adverse effect of having a nasogastric tube in place.

3. A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?

• A. Abdominal cramps
• B. Irritability
• C. Increased thirst
• D. Blurred vision

Correct answer: B

Rationale: Irritability is a common early manifestation of hypoglycemia. When blood glucose levels drop, the brain perceives this as a stressor, leading to irritability. Abdominal cramps (choice A) are not typically associated with hypoglycemia but can occur with other gastrointestinal issues. Increased thirst (choice C) is more indicative of hyperglycemia rather than hypoglycemia. Blurred vision (choice D) is a symptom more commonly associated with hyperglycemia rather than hypoglycemia.

4. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

• A. You should lie down before taking this medication.
• B. You should take this medication on an empty stomach.
• C. You should never take a double dose if you miss one.
• D. You should store this medication in its original container at room temperature.

Correct answer: A

Rationale: The correct instruction for a client prescribed nitroglycerin sublingual tablets is to lie down before taking the medication. Nitroglycerin can cause a sudden drop in blood pressure leading to dizziness or fainting, so taking the medication while lying down helps prevent falls. Choice B is incorrect because nitroglycerin is usually taken on an empty stomach to enhance its absorption. Choice C is incorrect as taking a double dose of nitroglycerin can lead to low blood pressure and other adverse effects. Choice D is incorrect as nitroglycerin sublingual tablets should be stored in their original container at room temperature away from light and moisture, not in the refrigerator.

5. A client with gastroesophageal reflux disease (GERD) is being taught about lifestyle changes to manage the condition. Which of the following instructions should the nurse include?

• A. Avoid eating small, frequent meals.
• B. Sleep with the head of your bed elevated.
• C. Lie down after eating.
• D. Avoid drinking fluids with meals.

Correct answer: B

Rationale: The correct answer is B: 'Sleep with the head of your bed elevated.' Elevating the head of the bed helps reduce acid reflux by keeping the head higher than the stomach, preventing stomach acid from flowing back into the esophagus. Choices A, C, and D are incorrect. Avoiding eating small, frequent meals, lying down after eating, and drinking fluids with meals can exacerbate GERD symptoms by increasing stomach acid production and promoting acid reflux.

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