Nursing Elites

1. A nurse is assessing a client with diabetes who reports frequent episodes of hypoglycemia. What should the nurse recommend to prevent these episodes?

• A. Increase protein intake
• B. Monitor blood glucose levels frequently
• C. Increase the dose of insulin
• D. Reduce carbohydrate intake

Correct answer: B

Rationale: The correct recommendation to prevent hypoglycemic episodes in a client with diabetes who reports frequent episodes is to monitor blood glucose levels frequently. By monitoring blood glucose levels, the nurse can make necessary adjustments to insulin dosage and diet to maintain blood sugar levels within the target range. Increasing protein intake (Choice A) is not directly related to preventing hypoglycemia; it is more important to focus on balancing carbohydrates and insulin. Increasing the dose of insulin (Choice C) without proper monitoring can lead to further hypoglycemic episodes. Similarly, reducing carbohydrate intake (Choice D) should be done cautiously as carbohydrates are a main source of energy and sudden reduction can cause hypoglycemia in diabetic patients.

2. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

3. When administering a subcutaneous injection of insulin to a client, what angle should the nurse use for the injection?

• A. 45-degree angle
• B. 60-degree angle
• C. 90-degree angle
• D. 30-degree angle

Correct answer: C

Rationale: The correct angle for administering a subcutaneous injection, such as insulin, is 90 degrees. This angle allows for the medication to be delivered into the subcutaneous layer of tissue beneath the skin. A 45-degree angle is typically used for administering subcutaneous injections in infants or those with reduced adipose tissue, while a 60-degree angle is commonly used for intramuscular injections. A 30-degree angle is not a standard angle for subcutaneous injections.

4. A client with renal calculi is admitted. What is the priority nursing intervention?

• A. Monitor urinary output every shift.
• B. Administer pain medication as ordered.
• C. Strain all urine for stones.
• D. Increase fluid intake to flush the urinary tract.

Correct answer: C

Rationale: The correct answer is to strain all urine for stones. This is the priority nursing intervention for a client with renal calculi as it helps in identifying and preventing stones from passing unnoticed. Monitoring urinary output, administering pain medication, and increasing fluid intake are important aspects of care for this client, but the priority is to ensure that any passed stones are collected and analyzed to guide further treatment.

5. After unsuccessful alternatives, a patient requires restraints. The nurse is reviewing the orders. Which findings indicate to the nurse the order is legal and appropriate for safe care?

• A. The health care provider writes the type and location of the restraint.
• B. The health care provider renews orders for restraints every 24 hours.
• C. The health care provider performs a face-to-face assessment prior to the order.
• D. The health care provider orders restraints PRN (as needed).

Correct answer: A

Rationale: In the context of restraining a patient, it is crucial for the health care provider to specify the type and location of the restraint in the order to ensure the safety and well-being of the patient. This information helps guide the nursing staff in the safe application of restraints. Renewing orders every 24 hours ensures that the need for restraints is continually assessed, promoting patient safety. Performing a face-to-face assessment before ordering restraints allows for a thorough evaluation of the patient's condition and the necessity of using restraints. Ordering restraints PRN (as needed) is not appropriate for safe care as it lacks specificity and may lead to inconsistent application and monitoring.

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