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 healthcare provider is reviewing laboratory results for a client who is receiving heparin therapy. Which of the following results indicates that the medication is effective?

• A. Platelets 250,000/mm³
• B. aPTT 60 seconds
• C. Hemoglobin 15 g/dL
• D. INR 1.5

Correct answer: B

Rationale: An aPTT of 60 seconds indicates that the client is receiving an effective dose of heparin. The activated partial thromboplastin time (aPTT) measures the time it takes for blood to clot and is used to monitor heparin therapy. A therapeutic range for aPTT during heparin therapy is usually 1.5 to 2 times the control value, which is around 25-35 seconds. Platelets, hemoglobin, and INR values are not direct indicators of the effectiveness of heparin therapy.

3. What is the best way to assess for fluid overload in a patient with heart failure?

• A. Check daily weight
• B. Check blood pressure
• C. Monitor heart sounds
• D. Assess for jugular vein distention

Correct answer: A

Rationale: The correct answer is to 'Check daily weight.' Monitoring daily weight is the most accurate method to assess for fluid overload in patients with heart failure. Weight gain can indicate fluid retention, a common issue in heart failure patients. Checking blood pressure (Choice B) can provide information about hemodynamic status but may not be as specific for fluid overload as monitoring weight. Monitoring heart sounds (Choice C) can provide information about cardiac function but may not directly assess fluid overload. Assessing for jugular vein distention (Choice D) can be a sign of increased central venous pressure but may not always correlate with fluid overload as accurately as daily weight checks.

4. How should fluid balance be assessed in a patient with heart failure?

• A. Monitor daily weight
• B. Monitor input and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: In patients with heart failure, monitoring daily weight is the most accurate method for assessing fluid balance. Weight gain can indicate fluid retention, a common issue in heart failure patients. Monitoring input and output (B) is essential but may not always accurately reflect fluid balance. Checking for edema (C) is important as it can indicate fluid accumulation, but daily weight monitoring is more precise. Monitoring blood pressure (D) is important in heart failure management but does not directly assess fluid balance.

5. What is the best intervention for a patient experiencing respiratory distress?

• A. Administer oxygen
• B. Administer bronchodilators
• C. Administer IV fluids
• D. Provide humidified air

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

Similar Questions