Nursing Elites

1. The nurse is teaching a client with diabetes mellitus how to differentiate between hypoglycemia and ketoacidosis. What statement indicates to the nurse that the client has an understanding of this condition?

• A. Glucose should be taken if I have a fruity breath odor.
• B. Glucose should be taken if I am urinating more than usual.
• C. Glucose should be taken if I have blurred vision.
• D. Glucose should be taken if I develop shakiness.

Correct answer: D

Rationale: The correct answer is D. Shakiness is a symptom of hypoglycemia, which is low blood sugar. Taking glucose can help raise blood sugar levels quickly in this situation. Fruity breath odor and excessive urination are signs of ketoacidosis, a complication of diabetes involving high levels of ketones in the blood. Blurred vision can be a symptom of high blood sugar, but it is not specific to hypoglycemia.

2. A client with a prescription for a transcutaneous electrical nerve stimulator (TENS) unit for pain management asks how it works. What information should the nurse reinforce?

• A. The discharge of electricity will distract the client's focus from the pain
• B. An infusion of medication in the spinal canal will block pain perception
• C. Pain perception in the cerebral cortex is dulled by the unit's discharge of an electrical stimulus
• D. A mild electrical stimulus on the skin surface closes the gates of nerve conduction for severe pain

Correct answer: D

Rationale: The correct answer is D. TENS works by delivering a mild electrical stimulus that can block pain signals from reaching the brain, effectively reducing the perception of pain. Choice A is incorrect because TENS does not distract from pain but rather interferes with pain signals. Choice B is incorrect as TENS does not involve infusing medication into the spinal canal. Choice C is also incorrect because TENS does not target the cerebral cortex to dull pain perception but rather works at the level of nerve conduction.

3. Which is the most important safety measure when administering a medication through a patient’s central venous catheter (CVC)?

• A. Using a sterile technique
• B. Ensuring correct placement of the CVC
• C. Flushing the CVC with saline after administration
• D. Monitoring for signs of infection

Correct answer: B

Rationale: The most important safety measure when administering a medication through a patient’s central venous catheter (CVC) is ensuring the correct placement of the CVC. This is crucial to prevent complications such as extravasation, infection, or improper drug delivery. While using a sterile technique, flushing the CVC with saline after administration, and monitoring for signs of infection are all important aspects of CVC care, ensuring the correct placement of the catheter takes precedence as it directly impacts patient safety during medication administration.

4. When caring for a child with sickle cell disease, the PN expects that the child will most likely describe which symptom when experiencing a sickle cell crisis?

• A. Decreased hemoglobin
• B. Joint pain
• C. Fatigue
• D. Infection

Correct answer: B

Rationale: During a sickle cell crisis, a child with sickle cell disease is most likely to describe joint pain. Sickle cell disease leads to the blockage of blood flow by sickled red blood cells, causing ischemia and pain, often felt in the joints and other body parts. Fatigue (choice C) is a nonspecific symptom that can occur in various conditions but is not a characteristic symptom of a sickle cell crisis. While decreased hemoglobin (choice A) can be observed in sickle cell disease, it is not a symptom typically described by a child during a sickle cell crisis. Infection (choice D) can trigger a sickle cell crisis but is not the symptom most likely to be described by the child during the crisis.

5. During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the practical nurse take?

• A. Record the findings and report the symptoms to the charge nurse
• B. Ask the family members to visit more often to stimulate the patient
• C. Motivate the client by offering favorite foods as a prize
• D. Withhold any medications that may cause side effects

Correct answer: A

Rationale: The practical nurse should record the findings and report the symptoms to the charge nurse. These behaviors may indicate a serious underlying condition such as depression or physical illness. By reporting to the charge nurse, the client can receive appropriate assessment and intervention promptly. Choice B is incorrect as family visits may not address the root cause of the symptoms. Choice C is incorrect as it oversimplifies the situation and may not be effective in addressing the underlying issue. Choice D is incorrect because withholding medications without proper assessment and guidance can be harmful to the client's health.

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