Nursing Elites

1. A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?

• A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
• B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
• C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
• D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.

Correct answer: A

Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.

2. A healthcare professional is preparing to administer a subcutaneous injection. Which of the following actions should the healthcare professional take?

• A. Use a 1-inch needle.
• B. Insert the needle at a 90-degree angle.
• C. Use a tuberculin syringe.
• D. Aspirate before injecting.

Correct answer: B

Rationale: When administering a subcutaneous injection, it is important to insert the needle at a 90-degree angle to ensure proper medication delivery into the subcutaneous tissue. This angle helps prevent the medication from being injected too deeply or too superficially, ensuring optimal absorption and therapeutic effect. Choice A is incorrect because the needle length for a subcutaneous injection is typically shorter, around ⅝ to 1 inch. Choice C is incorrect as a tuberculin syringe is not commonly used for subcutaneous injections. Choice D is also incorrect as aspiration is not necessary for subcutaneous injections since there are minimal blood vessels in the subcutaneous tissue.

3. A client with chronic obstructive pulmonary disease (COPD) is being cared for by a nurse. Which of the following interventions should the nurse include in the plan of care?

• A. Encourage pursed-lip breathing.
• B. Administer oxygen at 6 L/min via nasal cannula.
• C. Place the client in a supine position.
• D. Restrict fluid intake to less than 1,500 mL/day.

Correct answer: A

Rationale: Encouraging pursed-lip breathing is essential for clients with COPD as it aids in improving ventilation and gas exchange. This technique helps keep the airways open longer during exhalation, preventing air trapping and promoting more effective breathing. Administering oxygen, placing the client in a supine position, or restricting fluid intake are not primary interventions for managing COPD and may not address the specific respiratory needs of the client.

4. In an emergency department, a provider is assessing a client with an acute head injury following a motor-vehicle crash. Which of the following findings should be prioritized?

• A. A Glasgow Coma Scale score of 13
• B. Clear fluid leaking from the nose
• C. Nausea and vomiting
• D. Anisocoria

Correct answer: B

Rationale: The priority finding is the clear fluid leaking from the nose, which could indicate a cerebrospinal fluid leak and potential brain injury. This requires immediate attention to assess for possible cerebrospinal fluid leak, which is a serious complication of head trauma and needs prompt intervention to prevent further complications. While a Glasgow Coma Scale score of 13 may indicate a mild alteration in consciousness, it is not as urgent as assessing for a cerebrospinal fluid leak. Nausea and vomiting are common symptoms after head injuries but do not take precedence over assessing for a potential cerebrospinal fluid leak. Anisocoria (unequal pupils) is also important to note but is not as urgent as identifying a possible cerebrospinal fluid leak in this scenario.

5. While assessing a client with fluid volume deficit, which of the following findings should the nurse expect?

• A. Bradycardia
• B. Increased skin turgor
• C. Dry mucous membranes
• D. Hypertension

Correct answer: C

Rationale: Dry mucous membranes are a classic clinical manifestation of fluid volume deficit. Dehydration leads to reduced fluid intake or excessive fluid loss, resulting in decreased moisture in the mucous membranes. Bradycardia, increased skin turgor, and hypertension are not typically associated with fluid volume deficit. Bradycardia is more commonly seen in conditions like hypothyroidism or increased intracranial pressure. Increased skin turgor is a sign of dehydration, not deficit. Hypertension is not a typical finding in fluid volume deficit.

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