Nursing Elites

1. The client is being educated by the nurse on home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia?

• A. 59 mg/dL (3.3 mmol/L)
• B. 75 mg/dL (4.2 mmol/L)
• C. 108 mg/dL (6 mmol/L)
• D. 119 mg/dL (6.6 mmol/L)

Correct answer: A

Rationale: A blood glucose level of 59 mg/dL (3.3 mmol/L) is considered hypoglycemia, which is an abnormally low blood sugar level. This level requires immediate attention as it can lead to symptoms such as confusion, shakiness, and even loss of consciousness if left untreated. Choices B, C, and D have blood glucose levels within the normal range or slightly higher, indicating euglycemia or normal blood sugar levels, and not hypoglycemia.

2. A nurse is conducting an assessment of a client who underwent thoracentesis of the right side of the chest 3 hours ago. Which findings does the nurse report to the physician? Select all that apply.

• A. Unequal chest expansion
• B. Pulse rate of 82 beats/min
• C. Respiratory rate of 22 breaths/min
• D. Diminished breath sounds in the right lung

Correct answer: A

Rationale: After thoracentesis, the nurse should assess the client for signs of pneumothorax, which include increased respiratory rate, dyspnea, retractions, unequal chest expansion, diminished breath sounds, and cyanosis. Unequal chest expansion is a key sign of pneumothorax due to the accumulation of air in the pleural space, causing the affected lung to collapse partially. Pulse rate and respiratory rate within normal ranges, like in choices B and C, are not the priority findings to report in this situation. Diminished breath sounds in the right lung could be expected after thoracentesis and may not necessarily indicate a complication like pneumothorax, making choice D less urgent to report.

3. Which of the following is the best indicator of fluid balance in a patient with heart failure?

• A. Daily weight measurements.
• B. Monitoring intake and output.
• C. Assessing skin turgor.
• D. Checking for peripheral edema.

Correct answer: A

Rationale: Daily weight measurements are the best indicator of fluid balance in a patient with heart failure. Changes in weight reflect fluid retention or loss more accurately than other methods. Monitoring intake and output (choice B) is essential but may not provide a comprehensive picture of fluid status. Skin turgor (choice C) and checking for peripheral edema (choice D) are more indicative of dehydration and fluid overload, respectively, rather than overall fluid balance.

4. A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this client’s care?

• A. Edema and pain
• B. Electrolyte and fluid imbalance
• C. Cardiac and respiratory status
• D. Mental health status

Correct answer: B

Rationale: The major concern for a client admitted with acute kidney injury (AKI) and a high urine output of 2000 mL/day is electrolyte and fluid imbalance. In AKI, there may be an inflammatory cause leading to proteins entering the glomerulus, resulting in fluid being held in the filtrate and causing polyuria. Electrolyte loss and fluid balance are critical to monitor and manage in AKI cases. Edema and pain are not typically associated with fluid loss. While changes in cardiac, respiratory, and mental health status can occur if electrolyte imbalance is not addressed, the primary focus should be on managing electrolyte and fluid balance to prevent further complications.

5. A client is receiving intermittent bolus feedings via a nasogastric tube. In which position should the nurse place the client once the feeding is complete?

• A. Supine
• B. Head of bed flat
• C. Left lateral position
• D. Head of bed elevated 30 to 45 degrees

Correct answer: B

Rationale: After intermittent bolus feedings through a nasogastric tube, the correct position for the client is to keep the head of the bed flat. This position helps prevent vomiting and aspiration. Placing the client in a supine position (choice A) can increase the risk of aspiration. The left lateral position (choice C) is not typically used after nasogastric tube feedings. Elevating the head of the bed 30 to 45 degrees (choice D) is suitable for continuous tube feedings to reduce the risk of aspiration, but for intermittent bolus feedings, keeping the head of the bed flat is preferred to prevent regurgitation and aspiration.

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