Nursing Elites

1. A nurse is providing discharge teaching to a client who has hypertension about monitoring blood pressure at home. Which of the following instructions should the nurse include?

• A. Use a cuff that is too loose for the arm.
• B. Place the cuff over clothing.
• C. Sit quietly for 5 minutes before measuring your blood pressure.
• D. Use the same arm for each reading.

Correct answer: C

Rationale: The correct answer is to instruct the client to sit quietly for 5 minutes before measuring their blood pressure. This allows the body to relax and stabilize, leading to a more accurate reading. Choice A is incorrect because using a cuff that is too loose can result in inaccurate readings. Choice B is incorrect as the cuff should be placed directly on the bare skin. Choice D is incorrect as using the same arm for each reading is important for consistency in monitoring, but sitting quietly before measuring is crucial for accuracy.

2. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?

• A. I will check my blood glucose levels only when I feel sick.
• B. I will inject insulin in the same spot each time.
• C. I will rotate injection sites within the same anatomical region.
• D. I will inject insulin only if my blood glucose level is above 200 mg/dL.

Correct answer: C

Rationale: The correct answer is C. Clients with type 1 diabetes should rotate injection sites within the same anatomical region to prevent lipodystrophy. Choice A is incorrect because blood glucose levels should be checked regularly, not only when feeling sick. Choice B is incorrect as injecting insulin in the same spot each time can lead to lipodystrophy. Choice D is incorrect as insulin injections are usually required based on meal schedules and blood glucose levels, not just when levels are above 200 mg/dL.

3. A client who is at 12 weeks of gestation and has hyperemesis gravidarum is being cared for by a nurse. Which of the following laboratory values should the nurse report to the provider?

• A. Sodium 140 mEq/L
• B. Potassium 3.8 mEq/L
• C. Blood glucose 90 mg/dL
• D. Urine ketones present

Correct answer: D

Rationale: The correct answer is D: Urine ketones present. The presence of urine ketones indicates dehydration and inadequate glucose control in clients with hyperemesis gravidarum. Reporting this finding to the provider is crucial for prompt intervention to prevent further complications. Choices A, B, and C are within normal ranges and do not directly correlate with the condition of hyperemesis gravidarum. Therefore, they are not the priority values to report in this scenario.

4. A nurse is planning care for a group of clients. Which of the following clients should the nurse plan to assess first?

• A. A client who has a fractured femur and reports feeling short of breath.
• B. A client who is postoperative and has abdominal distention.
• C. A client who is receiving IV fluids and has a temperature of 38.5°C (101.3°F).
• D. A client who has cancer and has been receiving radiation therapy.

Correct answer: A

Rationale: The correct answer is A. A client with a fractured femur and reports feeling short of breath is at risk for a fat embolism, which is a medical emergency. The nurse should assess this client first to rule out this serious complication. Choice B may indicate paralytic ileus, which is important but not immediately life-threatening compared to a fat embolism. Choice C has a fever, which indicates infection but is not as urgent as a potential fat embolism. Choice D, a client receiving radiation therapy, is not experiencing an acute, life-threatening complication that requires immediate assessment compared to a fat embolism.

5. A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make?

• A. I can give you information about respite care if you are interested.
• B. You should consider taking a sleeping pill before bed each night.
• C. It must be difficult taking care of someone who is terminally ill.
• D. You are doing a great job taking care of your mother.

Correct answer: A

Rationale: Offering information about respite care is a therapeutic response that supports the caregiver. Choice B suggests a quick fix with sleeping pills without addressing the underlying issue of caregiver stress. Choice C, though empathetic, does not offer practical assistance or support. Choice D, while positive, does not address the son's need for rest and support.

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