Nursing Elites

1. A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. Hemoglobin A1c of 6%
• B. Fasting blood glucose of 90 mg/dL
• C. Blood glucose of 200 mg/dL
• D. Blood glucose of 100 mg/dL

Correct answer: C

Rationale: A blood glucose level of 200 mg/dL indicates hyperglycemia and should be reported for potential insulin adjustment.

2. A nurse is providing teaching to a client who is to start taking digoxin. Which of the following statements by the client indicates an understanding of the teaching?

• A. I should take this medication with food.
• B. I will contact my provider if my heart rate is below 60 beats per minute.
• C. I should take an antacid with this medication to prevent gastrointestinal upset.
• D. I will need to take this medication for 14 days.

Correct answer: B

Rationale: The client should contact their provider if their heart rate drops below 60 beats per minute, as this could indicate digoxin toxicity.

3. A healthcare professional is reviewing the medical record of a client who underwent surgery for a hip fracture. Which of the following findings should the healthcare professional report to the provider?

• A. Clear lung sounds
• B. Fever
• C. Pain in the operative leg
• D. Capillary refill of 2 seconds

Correct answer: B

Rationale: The correct answer is B: Fever. Fever in a postoperative client can indicate an infection, which is a serious complication and should be reported immediately to the provider for further evaluation and management. Clear lung sounds (Choice A) are a positive finding indicating normal respiratory function. Pain in the operative leg (Choice C) is expected postoperatively and should be managed with appropriate pain relief measures. Capillary refill of 2 seconds (Choice D) is within the normal range (less than 3 seconds) and is not a concerning finding postoperatively.

4. A nurse is caring for a client who is experiencing post-traumatic stress disorder (PTSD). Which of the following manifestations should the nurse expect?

• A. Hyperactivity
• B. Hypervigilance
• C. Restlessness
• D. Avoidance of social situations

Correct answer: B

Rationale: The correct answer is B: Hypervigilance. Individuals with PTSD often experience hypervigilance, which involves being overly alert, easily startled, and constantly scanning their environment for potential threats. This heightened state of awareness is a common response to the trauma experienced. Choices A, C, and D are incorrect. Hyperactivity is not typically a primary manifestation of PTSD; restlessness may occur but is not as characteristic as hypervigilance, and although avoidance of social situations can be a symptom of PTSD, hypervigilance is more directly associated with the disorder.

5. A nurse is caring for a client who delivered a full-term newborn 16 hours ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?

• A. Administer pain medication
• B. Perform a fundal massage
• C. Check the baby's heart rate
• D. Apply an ice pack

Correct answer: B

Rationale: Performing a fundal massage is the priority action in a postpartum client experiencing excessive lochia discharge. Fundal massage helps prevent postpartum hemorrhage by ensuring the uterus contracts effectively. Administering pain medication, checking the baby's heart rate, and applying an ice pack are not the initial interventions needed to address excessive lochia discharge.

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