Nursing Elites

1. A postoperative client with a history of diabetes mellitus is showing signs of hyperglycemia. What should the nurse assess first?

• A. Assess for signs of infection.
• B. Monitor the client’s fluid intake and output.
• C. Check the client’s capillary blood glucose level.
• D. Assess the client’s serum potassium level.

Correct answer: C

Rationale: The correct answer is to check the client’s capillary blood glucose level first. In a postoperative client with a history of diabetes mellitus showing signs of hyperglycemia, assessing blood glucose levels is crucial to confirm hyperglycemia and initiate appropriate interventions. While signs of infection are important to assess due to the client's postoperative status and diabetic history, checking the blood glucose level takes precedence to address the immediate concern of hyperglycemia. Monitoring fluid intake and output is essential but not the priority in this scenario. Assessing the client’s serum potassium level is important for overall assessment but not the initial step when hyperglycemia is suspected.

2. What might be suggested to a client with fibrocystic breasts in an attempt to help relieve symptoms?

• A. Increase intake of high-calcium foods in your diet
• B. Wear a supportive bra during the day and at night
• C. Take over-the-counter pain relievers
• D. Perform regular breast massage

Correct answer: B

Rationale: The correct answer is B: 'Wear a supportive bra during the day and at night.' Wearing a supportive bra is essential for individuals with fibrocystic breasts as it helps relieve discomfort by providing necessary support to reduce strain on breast tissue. Option A is incorrect as high-calcium foods are not directly related to symptom relief in fibrocystic breasts. Option C is not the first-line recommendation and may not address the underlying issue. Option D, performing regular breast massage, is not typically recommended and may not provide significant relief for fibrocystic breast symptoms.

3. A client with diabetes mellitus reports feeling shaky, dizzy, and sweaty. The nurse checks the client's blood glucose level and it is 55 mg/dL. What is the nurse's next action?

• A. Give the client a glucagon injection
• B. Encourage the client to eat a high-protein snack
• C. Administer 15 grams of a fast-acting carbohydrate
• D. Recheck the blood glucose level in 15 minutes

Correct answer: C

Rationale: A blood glucose level of 55 mg/dL indicates hypoglycemia, which should be treated with a fast-acting carbohydrate to quickly raise the blood sugar. Administering 15 grams of a fast-acting carbohydrate, such as glucose tablets or juice, is the appropriate initial intervention for hypoglycemia. Giving a glucagon injection is reserved for severe cases or when the client is unconscious. Encouraging the client to eat a high-protein snack is not appropriate for treating acute hypoglycemia, as it is a slower-acting form of glucose. Rechecking the blood glucose level is important but should occur after providing immediate treatment to raise the blood sugar level.

4. A client with chronic heart failure is admitted with worsening dyspnea. What is the nurse's priority action?

• A. Administer oxygen at 2 liters per nasal cannula.
• B. Administer a diuretic as prescribed.
• C. Assess the client's lung sounds.
• D. Reposition the client to relieve dyspnea.

Correct answer: A

Rationale: In a client with chronic heart failure experiencing worsening dyspnea, the priority action for the nurse is to administer oxygen at 2 liters per nasal cannula. This helps improve oxygenation and alleviate respiratory distress. Administering a diuretic (Choice B) may be necessary but addressing oxygenation comes first. While assessing lung sounds (Choice C) is important, it is not the immediate priority when the client is in respiratory distress. Repositioning the client (Choice D) may help with comfort but does not address the underlying issue of inadequate oxygenation.

5. The nurse is caring for a client with chronic heart failure who is receiving digoxin therapy. The nurse reviews the client's lab results and notes that the serum potassium level is 3.0 mEq/L. What action should the nurse take next?

• A. Administer a potassium supplement
• B. Notify the healthcare provider
• C. Hold the next dose of digoxin
• D. Increase dietary potassium intake

Correct answer: C

Rationale: In clients receiving digoxin therapy, low potassium levels can increase the risk of digoxin toxicity. Therefore, when the nurse notes a serum potassium level of 3.0 mEq/L, it is crucial to hold the next dose of digoxin. Notifying the healthcare provider is essential to ensure appropriate interventions, such as potassium supplementation, can be implemented. Administering a potassium supplement without healthcare provider guidance may lead to rapid potassium level changes and potential adverse effects. Increasing dietary potassium intake alone may not promptly address the low serum potassium level in this acute situation.

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