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 preparing a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse include in the report?

• A. Hgb 12.8 g/dl.
• B. Potassium 4.2 mEq/L.
• C. RBC 4.4 million/mm3.
• D. Platelets 100,000/mm3.

Correct answer: D

Rationale: The correct answer is D: "Platelets 100,000/mm3." A platelet count of 100,000/mm3 is low and increases the client's risk for bleeding, which is crucial information to communicate during the change-of-shift report. Choices A, B, and C provide values within normal ranges and are not directly related to the client's postoperative status or risk for complications. Therefore, they are not the priority information to include in the report.

3. What are the signs and symptoms of a pulmonary embolism?

• A. Sudden shortness of breath
• B. Chest pain
• C. Cough with blood
• D. All of the above

Correct answer: D

Rationale: A pulmonary embolism can manifest with sudden shortness of breath, chest pain, and coughing up blood. These symptoms are classic presentations of a pulmonary embolism due to the blockage of blood flow to the lungs. Therefore, the correct answer is 'All of the above.' Each symptom alone can be seen in various other conditions, but when occurring together, they strongly suggest a pulmonary embolism. Sudden shortness of breath is due to decreased oxygenation, chest pain can result from the strain on the heart, and coughing with blood may indicate damage to the lung tissue. Choosing any single symptom would not encompass the full range of presentations seen in a pulmonary embolism.

4. 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.

5. A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching?

• A. Drink plenty of fluids after meals
• B. Increase sugar intake
• C. Eat smaller, more frequent meals
• D. Avoid foods high in sugar content

Correct answer: D

Rationale: The correct instruction the nurse should include in teaching a client with dumping syndrome is to 'Avoid foods high in sugar content.' Dumping syndrome occurs when high-sugar foods move too quickly into the small intestine, leading to symptoms like abdominal cramps, diarrhea, and bloating. By avoiding foods high in sugar content, the client can reduce these symptoms. Choices A, B, and C are incorrect. Drinking plenty of fluids after meals may exacerbate symptoms by speeding up the movement of food through the digestive system. Increasing sugar intake would worsen dumping syndrome symptoms. While eating smaller, more frequent meals is a good strategy, the key emphasis should be on avoiding high-sugar foods.

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