Nursing Elites

1. A client with diabetes mellitus is being taught by a nurse on managing hypoglycemia. Which of the following instructions should the nurse include?

• A. Avoid consuming carbohydrate-rich foods.
• B. Consume 15 grams of a fast-acting carbohydrate.
• C. Drink a glass of water to raise blood glucose levels.
• D. Eat a snack before exercising to prevent hypoglycemia.

Correct answer: B

Rationale: The correct answer is B: Consume 15 grams of a fast-acting carbohydrate. Consuming 15 grams of a fast-acting carbohydrate, such as glucose tablets or juice, helps raise blood glucose levels quickly in cases of hypoglycemia. Choice A is incorrect because avoiding carbohydrate-rich foods during hypoglycemia can worsen the condition. Choice C is incorrect as drinking water does not effectively raise blood glucose levels. Choice D is incorrect as eating a snack before exercising is more related to preventing exercise-induced hypoglycemia, not managing hypoglycemia.

2. A nurse is planning care for a client who has a new prescription for a peripheral intravenous (IV) catheter. Which of the following actions should the nurse take to prevent infection?

• A. Shave the hair at the insertion site.
• B. Cleanse the site with povidone-iodine.
• C. Wear sterile gloves when changing the dressing.
• D. Change the IV site every 48 to 72 hours.

Correct answer: D

Rationale: The correct action to prevent infection when caring for a client with a new peripheral IV catheter is to change the IV site every 48 to 72 hours. Shaving the hair at the insertion site can actually increase the risk of infection by causing microabrasions in the skin. While cleansing the site with povidone-iodine is important before insertion, it is not necessary to continue doing so once the IV is in place. Wearing sterile gloves when changing the dressing is crucial for maintaining aseptic technique but does not directly prevent infection related to the IV site itself.

3. A nurse is assessing a client who has a history of urinary incontinence. Which of the following findings should the nurse report to the provider?

• A. Urine output of 50 mL in 2 hours
• B. Presence of an indwelling urinary catheter
• C. Frequent urination at night
• D. Dark-colored urine

Correct answer: D

Rationale: The correct answer is D, dark-colored urine. Dark-colored urine can indicate various issues such as dehydration, liver problems, or blood in the urine, which could be concerning and require further evaluation by the provider. Choices A, B, and C are not necessarily findings that would need immediate reporting to the provider. A urine output of 50 mL in 2 hours might be low but could be influenced by various factors and might not always require immediate action. The presence of an indwelling urinary catheter is a known history and not a new finding. Frequent urination at night could be a symptom related to various conditions but may not be an urgent concern unless accompanied by other significant symptoms.

4. A nurse is caring for a client who is 36 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 92/min
• B. Serosanguineous wound drainage
• C. Yellow wound drainage
• D. Blood pressure of 118/76 mm Hg

Correct answer: C

Rationale: Yellow wound drainage can indicate infection, especially 36 hours postoperative, and should be reported to the provider promptly. Serosanguineous drainage is a normal finding in the early stages of wound healing, and a heart rate of 92/min and a blood pressure of 118/76 mm Hg are within normal ranges for a postoperative client. Therefore, the nurse should prioritize reporting the yellow wound drainage as it may require immediate intervention.

5. A nurse is caring for a client who has bipolar disorder and is experiencing acute mania. The nurse obtained a verbal prescription for restraints. Which of the following actions should the nurse take?

• A. Request a renewal of the prescription every 8 hours.
• B. Check the client's peripheral pulse every 30 minutes.
• C. Obtain a prescription for restraints within 4 hours.
• D. Document the client's condition every 15 minutes.

Correct answer: D

Rationale: In the scenario presented, the correct action for the nurse to take when caring for a client with a verbal prescription for restraints due to acute mania is to document the client's condition every 15 minutes. Documenting at regular intervals is essential to monitor the client's well-being, assess the effects of the restraints, and ensure the client's safety. Requesting a renewal of the prescription every 8 hours (Choice A) is not necessary as the focus should be on monitoring the client's condition. Checking the client's peripheral pulse every 30 minutes (Choice B) is important but not as crucial as documenting the overall condition. Obtaining a prescription for restraints within 4 hours (Choice C) is not the immediate action needed when a verbal prescription is already obtained.

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