Nursing Elites

1. An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply)

• A. Check his fingerstick glucose
• B. Assess his skin temperature and moisture
• C. Measure his pulse and BP
• D. All of the Above

Correct answer: D

Rationale: In this scenario, the patient is a young adult male with type 2 diabetes mellitus admitted for a hernia repair who is experiencing weakness and jitteriness. Checking his fingerstick glucose is crucial to assess his blood sugar levels, which can directly impact his symptoms. Assessing his skin temperature and moisture is important to evaluate his peripheral circulation and hydration status. Measuring his pulse and blood pressure helps in gauging his cardiovascular status. Therefore, all the actions mentioned in choices A, B, and C are appropriate for the nurse to implement in this situation to identify the underlying cause of the patient's symptoms. Choice D, 'All of the Above,' is the correct answer because all these actions are necessary for a comprehensive assessment of the patient's condition. Choices A, B, and C are incorrect individually as they each address different aspects of the patient's condition, and a holistic approach is needed to provide optimal care in this situation.

2. A client who has a history of hyperthyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?

• A. Facial puffiness and periorbital edema
• B. Hematocrit of 30%
• C. Cold and dry skin
• D. Further decline in LOC

Correct answer: D

Rationale: A further decline in LOC can indicate severe complications and requires immediate attention. This change may signify worsening neurological status, which could lead to life-threatening consequences if not addressed promptly. Choices A, B, and C may also be concerning in a client with a history of hyperthyroidism, but a further decline in LOC takes priority due to its potential for rapid deterioration and the need for urgent intervention.

3. Following a bout of diarrhea, which foods should be offered to the school-age child?

• A. Apricots and peaches
• B. Chocolate milk
• C. Applesauce and milk
• D. Bananas and rice

Correct answer: D

Rationale: After rehydration, it is important to offer foods that are nonirritating to the bowel to the child. Bananas and rice are considered the best options as they are least likely to irritate the gastrointestinal tract. Apricots, peaches, and applesauce are fruits that may cause GI irritation, while milk, including chocolate milk, can also be irritating to the bowel. Therefore, the optimal choice for a child recovering from diarrhea would be bananas and rice.

4. Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?

• A. Avoid coiling the tubing and keep it free of kinks.
• B. Cleanse the perineal area with soap and water twice daily.
• C. Keep the drainage bag lower than the level of the bladder.
• D. Drink 1,000 ml of fluids daily to irrigate the catheter.

Correct answer: C

Rationale: The most crucial instruction for a client with an indwelling urinary catheter post-bladder surgery is to keep the drainage bag positioned lower than the level of the bladder. This positioning prevents backflow of urine into the bladder, reducing the risk of infection. Choice A, avoiding coiling the tubing and keeping it free of kinks, is important to maintain proper flow but not as critical as ensuring the drainage bag is lower than the bladder. Choice B, cleansing the perineal area, is essential for overall hygiene but not directly related to catheter care instructions. Choice D, drinking fluids to irrigate the catheter, is not recommended as it may increase the risk of infection and should be guided by healthcare providers based on specific needs.

5. A client with AIDS has impaired gas exchange from a respiratory infection. Which assessment finding warrants immediate intervention by the nurse?

• A. Elevated temperature
• B. Generalized weakness
• C. Diminished lung sounds
• D. Pain when swallowing

Correct answer: D

Rationale: In a client with AIDS and impaired gas exchange from a respiratory infection, pain when swallowing can indicate esophageal involvement, such as esophagitis or an esophageal infection like candidiasis. These conditions can significantly impact the client's ability to take in nutrition and medications, leading to complications like dehydration and malnutrition. Therefore, immediate intervention is required to address the underlying cause and prevent further complications. Elevated temperature (choice A) may indicate infection but does not directly address the impaired gas exchange. Generalized weakness (choice B) and diminished lung sounds (choice C) are concerning but do not directly relate to the immediate need for intervention in the context of esophageal involvement in a client with impaired gas exchange.

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