Nursing Elites

1. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following actions should the nurse take?

• A. Administer insulin
• B. Administer glucagon
• C. Administer 4 oz of orange juice
• D. Administer 1 L of water

Correct answer: C

Rationale: Administering 4 oz of orange juice is the appropriate action for a client experiencing hypoglycemia due to diabetes mellitus. Orange juice contains simple sugars that can quickly raise blood glucose levels. Insulin (Choice A) would further lower blood sugar, worsening the condition. Glucagon (Choice B) is used in severe hypoglycemia when the client cannot take anything by mouth. Administering 1 L of water (Choice D) is not indicated in hypoglycemia treatment; the priority is to raise blood sugar levels. Therefore, the correct choice is to administer orange juice to address the low blood sugar in this situation.

2. A nurse is reviewing the laboratory results of a client who is undergoing screening for prostate cancer. The nurse should expect an elevation in which of the following laboratory values?

• A. Prostate-specific antigen (PSA)
• B. Human chorionic gonadotropin (hCG)
• C. Alpha-fetoprotein (AFP)
• D. Carcinoembryonic antigen (CEA)

Correct answer: A

Rationale: The correct answer is A: Prostate-specific antigen (PSA). PSA is a marker specifically used for prostate cancer screening. Elevated levels of PSA can indicate prostate cancer or other prostate-related issues, prompting the need for further diagnostic investigations. Choices B, C, and D are not typically associated with prostate cancer screening. Human chorionic gonadotropin (hCG) is related to pregnancy, alpha-fetoprotein (AFP) is associated with liver and germ cell tumors, and carcinoembryonic antigen (CEA) is linked to colorectal cancer.

3. A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). Which of the following interventions should the nurse include in the plan of care?

• A. Administer oxygen at 2L/min via nasal cannula
• B. Encourage pursed-lip breathing
• C. Position the client in high Fowler's position
• D. Encourage deep breathing and coughing

Correct answer: B

Rationale: The correct intervention for a client with COPD is to encourage pursed-lip breathing. Pursed-lip breathing helps improve oxygenation by preventing airway collapse, slowing down the breathing rate, and promoting better gas exchange. Administering oxygen at 2L/min via nasal cannula is not the first-line intervention as it can cause oxygen toxicity in COPD patients. Positioning the client in high Fowler's position may improve ventilation but does not specifically address the breathing technique required for COPD. Encouraging deep breathing and coughing is generally not recommended for clients with COPD as it can lead to air trapping and increased work of breathing.

4. A nurse is educating a client on how to use a cane due to left-leg weakness. What should the nurse include in the teaching?

• A. Use the cane on the stronger side
• B. Advance the cane and the weaker leg at the same time
• C. Use the cane on the weaker side
• D. Advance the cane 30 to 45 cm (12-18 in) with each step

Correct answer: A

Rationale: The correct answer is to use the cane on the stronger side. By doing so, the client will have better support and balance. Choice B is incorrect because advancing the cane and the weaker leg at the same time may lead to instability and falls. Choice C is incorrect as using the cane on the weaker side does not provide optimal support. Choice D is incorrect as advancing the cane 30 to 45 cm (12-18 in) with each step is not a standard recommendation for cane use.

5. A client with an NG tube is experiencing nausea and a decrease in gastric secretions. What should the nurse do first?

• A. Position the client on their left side
• B. Irrigate the NG tube with sterile water
• C. Replace the NG tube with a new one
• D. Increase the suction setting to relieve the blockage

Correct answer: B

Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This can help clear any blockages in the tube, which may be causing the symptoms. Positioning the client on their left side may be helpful for enteral feedings but is not the priority in this situation. Replacing the NG tube should not be the initial step unless irrigation fails to resolve the issue. Increasing the suction setting without attempting to clear the blockage can be harmful to the client.

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