Nursing Elites

1. A nurse is assessing a client who has diabetes mellitus and is experiencing hypoglycemia. Which of the following findings should the nurse expect?

• A. Tachycardia
• B. Dry mouth
• C. Diaphoresis
• D. Increased appetite

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common sign of hypoglycemia due to the activation of the sympathetic nervous system. Tachycardia (choice A) is more commonly associated with hyperglycemia. Dry mouth (choice B) is not a typical finding in hypoglycemia but may be seen in hyperglycemia. Increased appetite (choice D) is not a typical sign of hypoglycemia and is more commonly associated with hyperglycemia.

2. A patient is scheduled to receive a transfusion of packed RBCs. Which of the following actions should the nurse take?

• A. Prime IV tubing with 0.9% sodium chloride
• B. Use a 24-gauge IV catheter
• C. Obtain filterless IV tubing
• D. Place blood in the warmer for 1 hour

Correct answer: A

Rationale: Priming the IV tubing with 0.9% sodium chloride is crucial before administering packed RBCs as it prevents hemolysis and ensures the safe transfusion of blood. Using a smaller 20- to 22-gauge IV catheter is recommended for packed RBCs to prevent hemolysis due to the small tubing size and faster flow rate. Obtaining filterless IV tubing is incorrect as blood products should be administered through a specialized filter to prevent potential clots or contaminants from reaching the patient. Placing blood in the warmer for an hour is unnecessary and could lead to overheating, potentially causing harm to the patient.

3. A nurse is planning discharge teaching about cord care for the parents of a newborn. Which of the following instructions should the nurse include?

• A. The cord stump will fall off in 5 days.
• B. Contact the provider if the cord stump turns black.
• C. Clean the base of the cord with hydrogen peroxide daily.
• D. Keep the cord stump dry until it falls off.

Correct answer: D

Rationale: The correct instruction for cord care is to keep the cord stump dry until it falls off. This helps prevent infection and promotes healing. Choice A is incorrect because the timing of when the cord stump falls off can vary, usually between 1-3 weeks. Choice B is incorrect as a black cord stump can be a normal part of the healing process, so it is unnecessary to contact the provider for this reason. Choice C is incorrect because cleaning the cord with hydrogen peroxide daily is not recommended as it can delay healing and cause irritation.

4. What is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented?

• A. Administer acetaminophen
• B. Administer antibiotics
• C. Administer fluids
• D. Cool the patient with cold compresses

Correct answer: C

Rationale: Administering fluids is the appropriate action for a healthcare provider to take when a patient has a high fever and is disoriented. Dehydration can worsen confusion and other symptoms in such a situation. Administering acetaminophen or cooling the patient with cold compresses may help reduce the fever but does not address the underlying issue. Administering antibiotics is not indicated for a high fever and disorientation without knowing the cause.

5. A client with diabetes mellitus is receiving teaching from a nurse about foot care. Which of the following instructions should the nurse include?

• A. Soak your feet in warm water daily.
• B. Wear cotton socks.
• C. Use a heating pad to warm your feet.
• D. Trim toenails straight across.

Correct answer: D

Rationale: The correct answer is to trim toenails straight across. This instruction is crucial for clients with diabetes to prevent ingrown toenails, which can lead to infection. Soaking feet in warm water daily can increase the risk of skin breakdown. Cotton socks are recommended, but the priority in foot care for diabetes is proper nail trimming. Using a heating pad can also pose a burn risk for individuals with reduced sensation in their feet.

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