Nursing Elites

1. The nurse is caring for a 69-year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Test blood sugar every 2 hours using Accu-Chek
• B. Review signs of hyperglycemia with the family and client
• C. Administer insulin if the blood sugar is elevated
• D. Measure the client's urine output

Correct answer: D

Rationale: The correct answer is D because measuring urine output is a task that falls within the UAP's scope of practice and does not require clinical decision-making. Choice A is incorrect because testing blood sugar using Accu-Chek involves interpreting results and possible adjustments, which require a licensed healthcare provider. Choice B is incorrect as discussing signs of hyperglycemia involves education and interpretation that should be done by a nurse. Choice C is incorrect since administering insulin is a high-risk task that necessitates precise dosing and monitoring, thus should not be delegated to UAP.

2. In assessing a client with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep, and the client becomes lethargic. Which assessment data should the nurse obtain next?

• A. Pulse oximetry
• B. Blood glucose
• C. Arterial blood gases
• D. Serum electrolytes

Correct answer: B

Rationale: Deep, rapid respirations (Kussmaul respirations) and lethargy are signs of diabetic ketoacidosis (DKA), which occurs in uncontrolled type 1 diabetes. Checking the blood glucose is the priority to confirm hyperglycemia and guide immediate treatment. Pulse oximetry is not the priority in this situation as the issue is related to altered glucose levels, not oxygenation. Arterial blood gases and serum electrolytes may be important later in the management of DKA but are not the initial priority compared to confirming and addressing the hyperglycemia.

3. A client is admitted with a suspected gastrointestinal bleed. What assessment finding requires immediate intervention?

• A. Bright red blood in the vomit.
• B. Elevated blood pressure and heart rate.
• C. Coffee ground emesis.
• D. Dark, tarry stools.

Correct answer: D

Rationale: Dark, tarry stools indicate the presence of digested blood in the gastrointestinal tract, signifying a higher gastrointestinal bleed. This finding requires immediate intervention due to the potential severity of the bleed. Bright red blood in the vomit may indicate active bleeding but is not as concerning as digested blood. Elevated blood pressure and heart rate are common responses to bleeding but do not provide direct evidence of the source or severity of the bleed. Coffee ground emesis is indicative of partially digested blood and is a concern but not as urgent as dark, tarry stools.

4. The nurse is teaching a client with asthma to use a peak expiratory flow rate (PEFR) meter to manage asthma at home. The nurse knows the client understands the proper use of the meter when the client:

• A. Inhales as rapidly as possible when using the meter
• B. Records the highest of three readings
• C. Uses the meter after taking a bronchodilator
• D. Blows out forcefully into the meter after taking a deep breath

Correct answer: B

Rationale: The correct answer is B: 'Records the highest of three readings.' When using a peak expiratory flow rate (PEFR) meter, the client should record the highest of three readings to ensure an accurate measurement of their peak expiratory flow rate. Inhaling rapidly, using the meter after taking a bronchodilator, or blowing out forcefully into the meter after a deep breath are not correct techniques for using a PEFR meter and may lead to inaccurate results.

5. A client receiving heparin therapy experiences a drop in platelet count. What is the nurse's priority action?

• A. Continue to monitor the platelet count.
• B. Discontinue the heparin infusion.
• C. Administer platelet transfusion.
• D. Notify the healthcare provider immediately.

Correct answer: D

Rationale: The correct answer is D: Notify the healthcare provider immediately. A drop in platelet count during heparin therapy may indicate heparin-induced thrombocytopenia (HIT), a serious condition that increases the risk of clot formation. Immediate discontinuation of heparin is necessary to prevent further complications. Administering platelet transfusion without addressing the underlying cause can be harmful. Continuing to monitor the platelet count without taking immediate action can lead to delayed intervention. Notifying the healthcare provider promptly allows for assessment and initiation of alternative anticoagulation therapy to manage the client's condition effectively.

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