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 client is to undergo a liver biopsy. Which of the following instructions should the nurse provide to the client following the procedure?

• A. “Lie on your left side.”
• B. “Lie on your right side.”
• C. “Increase your fluid intake.”
• D. “Decrease your fluid intake.”

Correct answer: B

Rationale: Following a liver biopsy, the nurse should instruct the client to lie on the right side to promote hemostasis. This position helps apply pressure to the biopsy site, reducing the risk of bleeding. Instructing the client to lie on the left side (Choice A) would not provide the same benefit. Increasing fluid intake (Choice C) is generally beneficial post-procedure to prevent dehydration and promote healing. Decreasing fluid intake (Choice D) is not advisable as it can lead to dehydration and potential complications.

3. A nurse is developing a plan of care for a newborn who has hyperbilirubinemia and a prescription for phototherapy. Which of the following interventions should the nurse include?

• A. Check the newborn's temperature every 4 hours
• B. Apply moisturizing lotion to the newborn's skin every 4 hours
• C. Give the newborn 1 oz of glucose water every 4 hours
• D. Reposition the newborn every 2 to 3 hours

Correct answer: D

Rationale: Repositioning the newborn every 2 to 3 hours during phototherapy is important to expose all areas of the skin to light and facilitate the breakdown of bilirubin. Checking the newborn's temperature is important, but it should be done more frequently, such as every 4 hours, to monitor for any signs of overheating or hypothermia. Applying moisturizing lotion is not indicated during phototherapy as it may interfere with the treatment. Giving glucose water is not necessary for the management of hyperbilirubinemia.

4. A nurse is planning care for a patient who follows the Mormon belief system. What modifications should the nurse include to meet Mormon dietary practices?

• A. Offer only vegetarian meal options.
• B. Offer non-caffeinated beverage options.
• C. Offer kosher meals.
• D. Limit meat to only fish and poultry.

Correct answer: B

Rationale: The correct answer is B: Offer non-caffeinated beverage options. Mormons avoid caffeinated beverages, so providing non-caffeinated options aligns with their religious practices. Choice A is incorrect because offering only vegetarian meal options is not a specific requirement of the Mormon dietary practices. Choice C is incorrect as kosher meals are associated with Jewish dietary laws, not specific to the Mormon belief system. Choice D is incorrect as limiting meat to only fish and poultry is not a specific dietary requirement for Mormons.

5. A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate. The nurse should monitor the client for which of the following findings as an indication of magnesium toxicity?

• A. Decreased deep tendon reflexes
• B. Elevated blood pressure
• C. Increased urinary output
• D. Hyperreflexia

Correct answer: A

Rationale: The correct answer is A: Decreased deep tendon reflexes. Magnesium sulfate toxicity can lead to diminished deep tendon reflexes, respiratory depression, and decreased urine output. Diminished deep tendon reflexes are an early sign of magnesium toxicity and indicate the need to discontinue the infusion. Elevated blood pressure (choice B) is not typically associated with magnesium toxicity. Increased urinary output (choice C) is also not a common finding in magnesium toxicity. Hyperreflexia (choice D) is not consistent with the expected findings of magnesium toxicity, which typically causes decreased reflexes.

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