Nursing Elites

1. A nurse is caring for a client who has pneumonia. Which of the following manifestations should the nurse expect?

• A. Bradycardia
• B. Hypertension
• C. Tachypnea
• D. Hypothermia

Correct answer: C

Rationale: The correct answer is C: Tachypnea. When caring for a client with pneumonia, the nurse should expect tachypnea, which is rapid breathing. This occurs due to decreased oxygenation and lung function. Bradycardia (A) is not typically associated with pneumonia; instead, tachycardia may be present. Hypertension (B) is not a common manifestation of pneumonia; instead, hypotension may occur due to sepsis. Hypothermia (D) is not a typical finding in pneumonia; fever or an elevated temperature is more common.

2. What is the primary purpose of administering insulin to a patient with diabetes?

• A. Regulate blood glucose levels
• B. Increase metabolism
• C. Prevent complications
• D. Promote insulin sensitivity

Correct answer: A

Rationale: The correct answer is A: 'Regulate blood glucose levels.' Administering insulin to a patient with diabetes helps regulate blood glucose levels by facilitating the uptake of glucose into cells, thereby lowering high blood sugar levels. This process aims to prevent hyperglycemia and its associated complications. Choice B, 'Increase metabolism,' is incorrect as the primary role of insulin is not to increase metabolism directly. Choice C, 'Prevent complications,' is partially correct as regulating blood glucose through insulin administration does help prevent complications associated with uncontrolled diabetes, but it is not the primary purpose. Choice D, 'Promote insulin sensitivity,' is incorrect as insulin itself is administered to compensate for the lack of endogenous insulin in diabetic patients, rather than to promote sensitivity to it.

3. A client has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Massage the injection site after administering the medication.
• B. Pinch the skin while administering the injection.
• C. Administer the medication at bedtime.
• D. Aspirate before injecting the medication.

Correct answer: B

Rationale: When administering enoxaparin, it is important to pinch the skin to ensure proper subcutaneous injection. Massaging the injection site after administering the medication is not recommended. Administering the medication at bedtime is not a specific requirement for enoxaparin. Aspirating before injecting the medication is not necessary for subcutaneous injections like enoxaparin.

4. What is the priority nursing intervention for a patient experiencing an acute asthma attack?

• A. Administer bronchodilators
• B. Monitor oxygen saturation
• C. Provide supplemental oxygen
• D. Start IV fluids

Correct answer: A

Rationale: The correct answer is to administer bronchodilators. In an acute asthma attack, the priority is to open the airways and improve airflow. Bronchodilators like albuterol are crucial in providing immediate relief to the patient. Monitoring oxygen saturation (choice B) is important but administering bronchodilators takes precedence in managing the acute attack. Providing supplemental oxygen (choice C) may be necessary but addressing the airway obstruction with bronchodilators is the priority. Starting IV fluids (choice D) is not the priority in an acute asthma attack unless specifically indicated for other reasons such as dehydration.

5. How should a healthcare provider monitor a patient with fluid overload?

• A. Monitor daily weight
• B. Check for edema
• C. Monitor input and output
• D. Monitor blood pressure

Correct answer: A

Rationale: Monitoring daily weight is crucial in assessing fluid retention accurately in a patient with fluid overload. Changes in weight can indicate fluid accumulation or loss, providing valuable information for healthcare providers. Checking for edema (choice B) is important but may not always accurately reflect total body fluid status. Monitoring input and output (choice C) and blood pressure (choice D) are also essential aspects of patient assessment, but they may not directly reflect the extent of fluid overload as effectively as monitoring daily weight.

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