Nursing Elites

1. A patient reports abdominal cramping after enema administration. What action should the nurse take to relieve the discomfort?

• A. Lower the height of the solution container
• B. Increase the flow of enema solution
• C. Remove the enema tubing
• D. Stop the procedure

Correct answer: A

Rationale: The correct action to relieve abdominal cramping after enema administration is to lower the height of the solution container. This adjustment slows down the flow rate of the enema solution, which can help reduce discomfort by decreasing the pressure on the patient's abdomen. Increasing the flow of the enema solution (Choice B) would exacerbate the cramping by introducing more solution quickly. Removing the enema tubing (Choice C) is not necessary to address the cramping, and stopping the procedure (Choice D) may not be needed if adjusting the height of the solution container can resolve the issue.

2. What dietary modifications are recommended for a patient with pre-dialysis kidney disease?

• A. Limit phosphorus intake to 700 mg/day
• B. Increase sodium intake to 3 g/day
• C. Restrict protein intake to 0.55-0.60 g/kg/day
• D. Eat three large meals per day

Correct answer: A

Rationale: The correct answer is A: Limit phosphorus intake to 700 mg/day. Patients with pre-dialysis kidney disease should limit phosphorus intake to prevent further kidney damage. Excessive phosphorus can lead to mineral and bone disorders. Choice B is incorrect because increasing sodium intake is not recommended in pre-dialysis kidney disease. Choice C is incorrect as protein restriction is a common recommendation in advanced kidney disease, not pre-dialysis. Choice D is incorrect as eating three large meals per day is not a specific dietary modification for pre-dialysis kidney disease.

3. If a nurse misread a glucose reading as 210 mg/dL instead of 120 mg/dL and administered insulin, what should the nurse monitor for?

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

Correct answer: A

Rationale: The correct answer is to monitor for hypoglycemia. In this scenario, the nurse administered insulin based on an incorrect glucose reading, which could lead to a drop in blood sugar levels. Monitoring for hypoglycemia is crucial to prevent any adverse effects on the patient's health. Choice B, monitoring for hyperglycemia, is incorrect as the administration of insulin can lead to low blood sugar levels, not high. Choice C, administering glucose IV, is not the immediate action needed as monitoring for hypoglycemia comes first. Choice D, documenting the incident, is important but not the initial priority when patient safety is at risk.

4. 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.

5. What should the nurse monitor for in a patient with hypokalemia?

• A. Monitor for muscle weakness
• B. Check deep tendon reflexes (DTRs)
• C. Monitor for seizures
• D. Monitor for bradycardia

Correct answer: A

Rationale: The correct answer is to monitor for muscle weakness in a patient with hypokalemia. Hypokalemia, which is low potassium levels, can lead to muscle weakness due to its effects on neuromuscular function. Checking deep tendon reflexes (Choice B) is not typically associated with hypokalemia. Seizures (Choice C) are more commonly associated with low calcium levels rather than low potassium levels. Bradycardia (Choice D) is a symptom of hyperkalemia (high potassium levels) rather than hypokalemia.

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