Nursing Elites

1. A client has hypoglycemia and is conscious. Which of the following actions should the nurse take?

• A. Administer glucagon IM
• B. Give the client 4 oz of fruit juice
• C. Provide the client with peanut butter
• D. Give the client 1 L of water

Correct answer: B

Rationale: In conscious clients with hypoglycemia, the most appropriate action is to provide a rapidly absorbed carbohydrate source like fruit juice to raise blood glucose levels quickly. Administering glucagon intramuscularly (IM) is usually reserved for unconscious clients or those who are unable to take oral glucose. Providing peanut butter or water would not rapidly address the hypoglycemic state as fruit juice would.

2. A nurse is administering lorazepam to a client who is scheduled for surgery within 1 hr. Which of the following actions should the nurse take after administering the medication?

• A. Keep the client awake
• B. Instruct the client not to get out of bed
• C. Encourage the client to drink fluids
• D. Encourage early ambulation

Correct answer: B

Rationale: The correct answer is to instruct the client not to get out of bed. Lorazepam is a sedative that can cause drowsiness and impair coordination. By instructing the client not to get out of bed, the nurse helps prevent falls or injuries that could occur due to the medication's sedative effects. Choice A is incorrect as keeping the client awake may not be necessary and could lead to unnecessary discomfort. Choice C is incorrect as encouraging the client to drink fluids is not directly related to the administration of lorazepam. Choice D is incorrect as early ambulation is not safe immediately after administering a sedative medication.

3. Which nursing intervention is essential for a client diagnosed with heart failure?

• A. Encourage fluid intake to prevent dehydration
• B. Monitor the client's weight daily to assess fluid balance
• C. Increase sodium intake to prevent fluid retention
• D. Limit fluid intake to avoid overload

Correct answer: B

Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with heart failure. This intervention helps healthcare providers evaluate fluid retention or loss, which is crucial in managing heart failure. Choice A is incorrect because excessive fluid intake can worsen heart failure symptoms by causing fluid overload. Choice C is incorrect because increasing sodium intake can lead to fluid retention, exacerbating heart failure. Choice D is incorrect as limiting fluid intake excessively can also be harmful in heart failure management, potentially leading to dehydration.

4. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

• A. Family members who smoke should be at least 10 ft away from the client when oxygen is in use
• B. Nail polish should not be used near a client who is receiving oxygen
• C. A 'No Smoking' sign should be placed on the front door
• D. Cotton bedding and clothing should be replaced with items made from wool

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

5. A nurse is reinforcing teaching with a client about the client's recent diagnosis of multiple sclerosis. The client states, 'I am very upset and I want to be alone for a little while.' Which of the following responses should the nurse make?

• A. I see that you are feeling overwhelmed. I will come back when you are ready
• B. This is normal, and I will check on you later
• C. You are feeling frustrated. Let's talk about your concerns.
• D. You will feel better soon. Let me get you some water.

Correct answer: A

Rationale: Acknowledging the client's feelings and allowing them space demonstrates understanding and respect for their emotions.

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