Nursing Elites

1. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?

• A. Diaphoresis
• B. Polyuria
• C. Abdominal pain
• D. Thirst

Correct answer: A

Rationale: The correct answer is A: Diaphoresis. Diaphoresis (sweating) is a classic symptom of hypoglycemia, along with shakiness, confusion, and irritability. These signs help indicate low blood sugar levels. Choices B, C, and D are incorrect. Polyuria (excessive urination), abdominal pain, and thirst are not typical symptoms associated with hypoglycemia. It is crucial for clients with type 1 diabetes mellitus to recognize the early signs of hypoglycemia to take prompt corrective action.

2. A nurse is planning care for a newly admitted adolescent with bacterial meningitis. What intervention should the nurse include?

• A. Initiate droplet precautions
• B. Assist the client to a supine position
• C. Perform a Glasgow Coma Scale every 24 hours
• D. Recommend prophylactic acyclovir for the client's family

Correct answer: A

Rationale: The correct intervention for a newly admitted adolescent with bacterial meningitis is to initiate droplet precautions. Bacterial meningitis is highly contagious, and droplet precautions are necessary to prevent the spread of infection. Assisting the client to a supine position (Choice B) is not directly related to managing bacterial meningitis. Performing a Glasgow Coma Scale every 24 hours (Choice C) may be important to assess the client's neurological status but is not the priority intervention in preventing the spread of infection. Recommending prophylactic acyclovir for the client's family (Choice D) is not a standard practice in the care of a patient with bacterial meningitis.

3. What is the name of a legal document that instructs health care providers and family members about what life-sustaining treatment an individual wants if they are unable to make decisions?

• A. Do Not Resuscitate
• B. Informed consent
• C. Living will
• D. Durable power of attorney for health care

Correct answer: C

Rationale: The correct answer is C, 'Living will.' A living will is a legal document that outlines an individual's preferences for life-sustaining medical treatment if they become unable to make decisions. Choice A, 'Do Not Resuscitate,' specifically refers to a directive that instructs healthcare providers not to perform CPR. Choice B, 'Informed consent,' pertains to a patient's right to be informed about and consent to medical treatment. Choice D, 'Durable power of attorney for health care,' involves appointing someone to make healthcare decisions on behalf of an individual when they are unable to do so.

4. A nurse is providing teaching to a client with a new diagnosis of diabetes mellitus. Which instruction should the nurse give to the client to monitor for hypoglycemia?

• A. Monitor for polyuria
• B. Monitor for diaphoresis
• C. Monitor for abdominal pain
• D. Monitor for thirst

Correct answer: B

Rationale: The correct answer is B: 'Monitor for diaphoresis.' Diaphoresis, which refers to excessive sweating, is a common symptom of hypoglycemia. It indicates a low blood sugar level and should prompt immediate treatment. Polyuria (excessive urination), abdominal pain, and thirst are not typically associated with hypoglycemia. Polyuria is more commonly linked to hyperglycemia, while abdominal pain and thirst are not specific symptoms of hypoglycemia.

5. A nurse is assessing a client who has a history of atrial fibrillation and is receiving warfarin. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the warfarin?

• A. Platelet count
• B. International normalized ratio (INR)
• C. Bleeding time
• D. Partial thromboplastin time (PTT)

Correct answer: B

Rationale: The correct answer is B: International normalized ratio (INR). The INR is used to monitor the effectiveness of warfarin therapy. A higher INR indicates a longer time it takes for the blood to clot, which is desirable in patients receiving warfarin to prevent blood clots. Platelet count (Choice A) assesses the number of platelets in the blood and is not directly related to warfarin therapy. Bleeding time (Choice C) evaluates the time it takes for a person to stop bleeding after a standardized wound, but it is not specific to monitoring warfarin effectiveness. Partial thromboplastin time (PTT) (Choice D) is more commonly used to monitor heparin therapy, not warfarin.

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