Nursing Elites

1. A nurse is teaching a client who has a new diagnosis of diabetes mellitus about managing blood glucose levels. Which of the following client statements indicates an understanding of the teaching?

• A. "I will monitor my blood pressure regularly."
• B. "I will keep my blood glucose level between 200 and 250 mg/dL."
• C. "I will take my insulin at the same time each day."
• D. "I will eat three large meals each day."

Correct answer: C

Rationale: Taking insulin at the same time each day helps maintain stable blood glucose levels and prevent complications.

2. A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, 'It's hard not to listen to the voices.' Which of the following questions should the nurse ask?

• A. Do you understand that the voices are not real?
• B. Why do you think the voices are talking to you?
• C. Have you tried going to a private place when this occurs?
• D. What helps you ignore what you are hearing?

Correct answer: D

Rationale: The correct answer is 'D: What helps you ignore what you are hearing?' Asking the client about coping mechanisms is essential in assisting them to manage auditory hallucinations. Choice A is incorrect as questioning the reality of the voices may not be helpful. Choice B delves into the cause of the hallucinations rather than coping strategies. Choice C focuses on isolation rather than addressing the client's coping mechanisms.

3. A nurse is caring for a client who is receiving oxytocin IV for augmentation of labor. The client's contractions are occurring every 45 seconds with a nine-second duration, and the fetal heart rate is 170 to 180 beats per minute. Which of the following actions should the nurse take?

• A. Discontinue oxytocin infusion
• B. Increase oxytocin infusion
• C. Decrease oxytocin infusion
• D. Maintain oxytocin infusion

Correct answer: A

Rationale: In this scenario, the client is experiencing frequent contractions with a short duration and an elevated fetal heart rate, indicating potential fetal distress. Discontinuing the oxytocin infusion is crucial to prevent further complications and restore normal fetal parameters. Increasing or maintaining the oxytocin infusion could exacerbate the situation, leading to more distress for the fetus. Decreasing the oxytocin infusion may not be sufficient to address the current issue and could delay the improvement of fetal well-being.

4. A nurse is caring for a client who has a new prescription for levothyroxine. Which of the following laboratory values should the nurse monitor to determine the effectiveness of the medication?

• A. Calcium
• B. Sodium
• C. Thyroid-stimulating hormone (TSH)
• D. Magnesium

Correct answer: C

Rationale: The correct answer is C: Thyroid-stimulating hormone (TSH). Monitoring TSH levels is crucial to assess the effectiveness of levothyroxine in clients with hypothyroidism. TSH is produced by the pituitary gland and stimulates the thyroid gland to produce thyroid hormones. In hypothyroidism, where the thyroid gland is underactive, administering levothyroxine helps to normalize thyroid hormone levels. Monitoring TSH levels allows the healthcare provider to adjust the levothyroxine dosage to ensure that thyroid hormone levels are within the therapeutic range. Choices A, B, and D (Calcium, Sodium, and Magnesium) are not directly related to assessing the effectiveness of levothyroxine therapy in hypothyroidism and would not provide relevant information regarding the medication's efficacy.

5. A nurse is planning care for a client who is 6 hours postoperative following a total hip arthroplasty. Which of the following interventions should the nurse include in the plan of care?

• A. Place a wedge under the client's affected leg.
• B. Keep the client's hip flexed at a 90° angle.
• C. Position the client with the legs extended and the hip externally rotated.
• D. Keep the client's leg abductor pillow in place while in bed.

Correct answer: D

Rationale: In caring for a client 6 hours postoperative following a total hip arthroplasty, it is crucial to keep the leg abductor pillow in place while in bed. This intervention helps prevent hip dislocation by maintaining proper alignment and stability of the hip joint. Placing a wedge under the client's affected leg (Choice A) may not provide adequate support and could potentially compromise the surgical site. Keeping the client's hip flexed at a 90° angle (Choice B) or positioning the client with the legs extended and the hip externally rotated (Choice C) are not recommended post total hip arthroplasty as they may increase the risk of hip dislocation.

Similar Questions