Nursing Elites

1. An older adult client visits the community health clinic and reports the onset of pain, redness, and swelling of the right eye. Which question is most important for the clinic nurse to ask the client?

• A. Do you have any discharge from the eye?
• B. Have you started any new prescriptions?
• C. Are all of your immunizations current?
• D. How often do you wash your hands?

Correct answer: B

Rationale: The most important question for the nurse to ask the client is whether they have started any new prescriptions. New medications can have side effects that include eye issues, so it is crucial to determine if there is a potential link. Asking about discharge from the eye (Choice A) may be relevant but does not address the possibility of medication side effects. Inquiring about immunizations (Choice C) and handwashing frequency (Choice D) is important for overall health but is less directly related to the eye symptoms described by the client.

2. The healthcare provider is preparing to administer atropine, an anticholinergic, to a client scheduled for a cholecystectomy. The client asks the provider to explain the reason for the prescribed medication. What response is best for the provider to provide?

• A. To increase gastric motility.
• B. To decrease the risk of bradycardia during surgery.
• C. To reduce secretions.
• D. To prevent nausea and vomiting.

Correct answer: B

Rationale: Atropine, an anticholinergic medication, is used preoperatively to prevent bradycardia by increasing the automaticity of the sinoatrial node during surgical anesthesia. Choice A is incorrect because atropine does not affect gastric motility. Choice C is incorrect as atropine is not primarily used to reduce secretions. Choice D is also incorrect because preventing nausea and vomiting is not the primary purpose of administering atropine in this context.

3. The healthcare provider is assessing a client who has returned from hemodialysis. Which finding requires immediate intervention?

• A. Weight gain of 1 pound.
• B. Dizziness.
• C. Fatigue.
• D. Muscle cramps.

Correct answer: D

Rationale: After hemodialysis, muscle cramps can indicate an electrolyte imbalance, such as low potassium or magnesium levels, which requires immediate intervention to prevent potential complications like cardiac arrhythmias. Weight gain of 1 pound, dizziness, and fatigue are common post-hemodialysis symptoms that may not necessarily require immediate intervention unless they are severe or persisting.

4. A client with a history of diabetes mellitus is admitted with hypoglycemia. Which finding requires immediate intervention?

• A. Blood glucose of 60 mg/dL.
• B. Heart rate of 100 beats per minute.
• C. Tremors.
• D. Diaphoresis.

Correct answer: C

Rationale: In a client with a history of diabetes mellitus admitted with hypoglycemia, the finding that requires immediate intervention is tremors. Tremors can indicate severe hypoglycemia, which needs prompt attention to prevent complications such as seizures or loss of consciousness. While a blood glucose level of 60 mg/dL is low, the presence of tremors signifies a more urgent situation. A heart rate of 100 beats per minute and diaphoresis are common physiological responses to hypoglycemia and do not necessarily require immediate intervention unless other severe symptoms are present.

5. A client with a history of alcohol abuse is admitted with acute pancreatitis. Which laboratory result requires immediate intervention?

• A. Amylase of 120 U/L.
• B. Lipase of 150 U/L.
• C. Calcium of 8.5 mg/dL.
• D. Blood glucose of 250 mg/dL.

Correct answer: D

Rationale: The correct answer is D, 'Blood glucose of 250 mg/dL.' In a client with acute pancreatitis, elevated blood glucose levels can indicate poor control of diabetes or stress response from the acute illness. Immediate intervention is necessary to prevent complications like worsening pancreatitis, infections, or other metabolic issues. Choices A and B, 'Amylase of 120 U/L' and 'Lipase of 150 U/L,' are commonly elevated in pancreatitis but do not require immediate intervention unless significantly elevated. Choice C, 'Calcium of 8.5 mg/dL,' is within the normal range and not a priority in this scenario.

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