Nursing Elites

1. The client with newly diagnosed type 1 diabetes mellitus is being taught about insulin administration by the nurse. Which statement indicates that the client needs further teaching?

• A. I will inject my insulin into my abdomen for the fastest absorption.
• B. I will rotate injection sites to prevent lipodystrophy.
• C. I will store my insulin in the refrigerator at all times.
• D. I will rotate injection sites to prevent lipodystrophy.

Correct answer: C

Rationale: The correct answer is C. Insulin should not be stored in the refrigerator at all times; it should be kept at room temperature when in use to avoid irritation at the injection site. Storing insulin in the refrigerator can cause it to thicken and may lead to discomfort upon injection. Choices A and D are correct statements as injecting insulin into the abdomen for faster absorption and rotating injection sites to prevent lipodystrophy are appropriate insulin administration techniques. Therefore, the client does not need further teaching on these aspects.

2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which finding indicates that the therapy is effective?

• A. The client is able to expectorate secretions easily.
• B. The client's oxygen saturation is 92%.
• C. The client's respiratory rate is 20 breaths per minute.
• D. The client's arterial blood gases show a pH of 7.35.

Correct answer: C

Rationale: In a client with COPD receiving oxygen therapy, an effective response is indicated by a respiratory rate of 20 breaths per minute. This suggests that the client is effectively oxygenating while maintaining an appropriate respiratory rate. Choices A, B, and D are incorrect because expectorating secretions easily, having an oxygen saturation of 92%, and arterial blood gases showing a pH of 7.35 are not specific indicators of the effectiveness of oxygen therapy in COPD. Oxygen saturation of 92% may still be suboptimal in COPD, and arterial blood gases showing a pH of 7.35 may not necessarily reflect the overall effectiveness of oxygen therapy.

3. The client with congestive heart failure (CHF) is receiving discharge instructions. Which statement by the client indicates a need for further teaching?

• A. I will weigh myself daily and report a weight gain of more than 2 pounds in 24 hours.
• B. I will take my diuretic medication in the morning.
• C. I will call my healthcare provider if I experience increased shortness of breath.
• D. I will drink at least 3 liters of fluid each day.

Correct answer: D

Rationale: The correct answer is D. Drinking at least 3 liters of fluid each day may be contraindicated for a client with CHF due to the risk of fluid overload. This can exacerbate heart failure symptoms and lead to complications. Options A, B, and C are all appropriate statements that demonstrate understanding of managing CHF and seeking appropriate medical attention when needed.

4. During a follow-up visit, a client with hypertension reports that they often forget to take their medication. What should the nurse do first?

• A. educate the client on the importance of medication adherence
• B. explore the reasons for the client's forgetfulness
• C. provide the client with a pill organizer
• D. adjust the client's medication schedule

Correct answer: B

Rationale: The correct first action for the nurse is to explore the reasons for the client's forgetfulness. By understanding the underlying causes, the nurse can provide tailored interventions to help the client improve medication adherence. Providing education on the importance of adherence (Choice A) may be necessary but should come after identifying the reasons for forgetfulness. Simply providing a pill organizer (Choice C) or adjusting the medication schedule (Choice D) does not address the root cause of the forgetfulness and may not lead to sustained improvement in adherence.

5. What is the most important information for a nurse to obtain when an older female client expresses not deserving to eat due to lack of money?

• A. Client's thoughts about wanting to hurt herself
• B. Medication history for antipsychotic agents
• C. Availability of family members to provide meals
• D. Community resources to provide financial aid

Correct answer: A

Rationale: The correct answer is A: Client's thoughts about wanting to hurt herself. When a client expresses not deserving to eat due to lack of money, it raises concerns about her mental and emotional well-being. Assessing for suicidal ideation is crucial in this situation to ensure the client's immediate safety. Options B, C, and D are not the most critical information to obtain in this scenario. While medication history, family support, and community resources are important aspects of care, in this context, the client's mental health and risk of self-harm take precedence.

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