Nursing Elites

1. A nurse is teaching a client who has type 1 DM about hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

• A. Exercise reduces the risk for hypoglycemia.
• B. I can skip my insulin when I don't eat.
• C. I can drink 4 oz of soda if my blood sugar is low.
• D. Diabetic pills don't cause hypoglycemia; only insulin does.

Correct answer: C

Rationale: The client can correct any development of hypoglycemia with a quick intake of glucose. The client should have 15 g carbohydrates on hand to treat hypoglycemic episodes, like 4 oz of regular soda.

2. Which lab value is a priority for a patient with HIV?

• A. CD4 T-cell count 180 cells/mm3
• B. Albumin levels below 3.5 g/dL
• C. Potassium levels below 3.5 mEq/L
• D. White blood cell count below 5000/mm3

Correct answer: A

Rationale: A CD4 T-cell count of less than 180 cells/mm3 is a priority for a patient with HIV because it indicates severe immunocompromise and an increased risk for opportunistic infections. Monitoring CD4 levels helps in assessing the immune status and guiding treatment decisions in patients with HIV. Albumin levels (choice B) are important for assessing nutritional status but are not a direct indicator of immune function in HIV patients. Potassium levels (choice C) and white blood cell count (choice D) are also important, but the CD4 T-cell count is specifically crucial for evaluating the immune function in individuals with HIV.

3. What dietary recommendations should be given to a patient with pre-dialysis end-stage kidney disease?

• A. Reduce phosphorus intake to 700 mg/day
• B. Increase sodium intake
• C. Increase protein intake
• D. Increase potassium intake

Correct answer: A

Rationale: The correct recommendation for a patient with pre-dialysis end-stage kidney disease is to reduce phosphorus intake to 700 mg/day. High phosphorus levels can lead to complications in such patients. Increasing sodium intake (Choice B) is generally not recommended due to its association with hypertension and fluid retention. While protein is essential, increasing protein intake (Choice C) in kidney disease can be harmful as it can lead to increased waste products that the kidneys may struggle to excrete. Increasing potassium intake (Choice D) is not advisable as well, as patients with kidney disease may already have difficulty excreting potassium, leading to hyperkalemia.

4. What should be monitored for in a patient with compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Localized redness and swelling
• C. Fever and infection
• D. Muscle weakness and fatigue

Correct answer: A

Rationale: Correct Answer: A. Unrelieved pain, pallor, and pulselessness are classic signs of compartment syndrome that indicate inadequate blood flow to the affected area. These symptoms are crucial to monitor as they signify a medical emergency requiring immediate intervention. Choices B, C, and D are incorrect because they do not align with the typical manifestations of compartment syndrome. Localized redness and swelling may be present but are not the primary indicators. Fever and infection are also not specific to compartment syndrome, and muscle weakness and fatigue are not typically prominent symptoms of this condition.

5. What should the nurse do when continuous bubbling is seen in the chest tube water seal chamber?

• A. Tighten the connections of the chest tube system
• B. Clamp the chest tube
• C. Replace the chest tube
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the nurse should tighten the connections of the chest tube system. This action can often resolve an air leak causing the continuous bubbling. Clamping the chest tube or replacing it would not address the underlying issue of an air leak and may lead to complications. Continuing to monitor the chest tube without taking corrective action may result in the deterioration of the patient's condition.

Similar Questions