Nursing Elites

1. A nurse misreads a glucose reading and administers insulin for a blood glucose of 210 instead of 120. What should the nurse monitor the patient for?

• A. Monitor for hyperglycemia
• B. Monitor for signs of hypoglycemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: B

Rationale: The correct answer is B: Monitor for signs of hypoglycemia. The nurse should monitor the patient for hypoglycemia due to the administration of excess insulin. Administering insulin for a blood glucose level of 210 instead of 120 can lead to a rapid drop in blood sugar levels, causing hypoglycemia. Option A is incorrect as hyperglycemia is high blood sugar, which is unlikely in this scenario. Option C is incorrect as administering glucose IV would worsen the hypoglycemia. Option D is not the immediate priority; patient safety and monitoring for adverse effects take precedence.

2. A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 minutes. After maintaining the client's airway and turning the client on their side, which of the following medications should the nurse administer?

• A. Diazepam IV
• B. Lorazepam PO
• C. Diltiazem IV
• D. Clonazepam PO

Correct answer: A

Rationale: In the scenario described, where the client has been experiencing repeated tonic-clonic seizures over an extended period, the priority is to administer a medication that can rapidly terminate the seizures. Diazepam is the medication of choice for status epilepticus due to its rapid onset of action within 10 minutes when administered intravenously. Lorazepam is also an option, but it is typically administered intravenously as well. Diltiazem is a calcium channel blocker used for conditions like hypertension and angina, not for seizures. Clonazepam, although used for seizures, is not the ideal choice in this acute situation due to its slower onset of action compared to benzodiazepines like diazepam and lorazepam.

3. When caring for a patient with hypokalemia, what should the nurse monitor for?

• A. Monitor for muscle weakness
• B. Check for cardiac dysrhythmias
• C. Monitor for bradycardia
• D. Monitor for seizures

Correct answer: A

Rationale: Corrected Answer: Muscle weakness is a common sign of hypokalemia. The nurse should monitor for muscle weakness as potassium plays a crucial role in muscle function. Choices B, C, and D are incorrect because although hypokalemia can lead to cardiac dysrhythmias, bradycardia, and even seizures in severe cases, muscle weakness is a more common and specific sign directly related to potassium levels.

4. What is the primary nursing action for a patient experiencing continuous bubbling in the chest tube water seal chamber?

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

Correct answer: A

Rationale: The correct answer is to tighten the connections of the chest tube system. Continuous bubbling in the chest tube water seal chamber indicates an air leak. By tightening the connections of the chest tube system, the nurse can often resolve the issue by ensuring there are no loose connections allowing air to enter. Clamping the chest tube or replacing the chest tube system are not appropriate actions in this situation. Clamping the tube can cause a dangerous buildup of pressure, while replacing the system should only be considered if tightening the connections does not resolve the air leak.

5. A patient experiencing wheezing due to an allergic reaction needs immediate treatment. Which medication should be administered first?

• A. Albuterol via nebulizer
• B. Cromolyn via nebulizer
• C. Aminophylline IV
• D. Methylprednisolone IV

Correct answer: A

Rationale: The correct answer is A: Albuterol via nebulizer. Albuterol is a rapid-acting bronchodilator that helps relieve wheezing by opening up the airways. During an allergic reaction causing wheezing, prompt relief is crucial, making Albuterol the first-line treatment. Choice B, Cromolyn via nebulizer, is used more for preventing asthma symptoms rather than providing immediate relief. Choice C, Aminophylline IV, is a bronchodilator with a slower onset of action compared to Albuterol. Choice D, Methylprednisolone IV, is a corticosteroid used to reduce inflammation and is not the first-line treatment for acute wheezing in an allergic reaction.

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