Nursing Elites

1. The nurse prepares to teach clients about blood glucose monitoring. When should clients always check glucose, regardless of age or type of diabetes?

• A. Before going to bed.
• B. After meals.
• C. During acute illness.
• D. Prior to exercising.

Correct answer: C

Rationale: The correct answer is C: During acute illness. Checking blood glucose during acute illness is crucial as stress can elevate glucose levels. This monitoring is essential regardless of the client's age or the type of diabetes they have. Checking before going to bed (choice A) may be important for some individuals, but it's not as universally necessary as during acute illness. Checking after meals (choice B) and prior to exercising (choice D) are important times for monitoring blood glucose, but they are not as universally applicable as during acute illness.

2. A client with hypertension is prescribed a low-sodium diet. What is the most important instruction for the nurse to provide?

• A. Limit sodium intake to 2 grams per day.
• B. Choose fresh fruits and vegetables.
• C. Drink at least 8 glasses of water daily.
• D. Avoid processed foods and canned soups.

Correct answer: D

Rationale: The correct answer is D. Avoiding processed foods and canned soups is crucial for a client with hypertension on a low-sodium diet because these foods are typically high in sodium content. Fresh fruits and vegetables are generally healthy choices but may still contain some natural sodium. While limiting sodium intake to 2 grams per day is important, specifically avoiding processed foods and canned soups is more critical in this situation. Drinking water is essential for overall health but is not the most important instruction when focusing on reducing sodium intake.

3. A client with type 2 diabetes mellitus is admitted for frequent hyperglycemic episodes and a glycosylated hemoglobin (A1C) of 10%. Insulin glargine 10 units subcutaneously once a day at bedtime and a sliding scale of insulin aspart every 6 hours are prescribed. What actions should the nurse include in this client's plan of care?

• A. Teach subcutaneous injection technique, site rotation, and insulin management
• B. Coordinate carbohydrate-controlled meals at consistent times and intervals
• C. Review with the client proper foot care and prevention of injury
• D. All of the above

Correct answer: D

Rationale: Effective diabetes management involves comprehensive care, including proper foot care, insulin administration technique, and maintaining carbohydrate consistency with meals. All of these interventions are critical in reducing hyperglycemic episodes and managing diabetes.

4. A client recently started on warfarin therapy. What laboratory value is most important to monitor for this client?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Creatinine level
• D. Blood urea nitrogen (BUN)

Correct answer: B

Rationale: Prothrombin time (PT) is the most important laboratory value to monitor for clients on warfarin therapy. PT helps determine how long it takes blood to clot and ensures the warfarin dose is within the therapeutic range to prevent either excessive bleeding or clotting. Monitoring platelet count is important for assessing the risk of bleeding, but PT is more specific to warfarin therapy. Creatinine level and BUN are indicators of kidney function and are not directly related to warfarin therapy.

5. A client with cirrhosis and ascites asks about fluid restriction. What is the nurse’s best response?

• A. Increase the client's fluid intake gradually.
• B. Restrict oral fluids to 1500 ml per day.
• C. Explain the importance of following a low-sodium diet.
• D. Increase dietary protein to reduce fluid retention.

Correct answer: B

Rationale: The correct answer is B: 'Restrict oral fluids to 1500 ml per day.' In clients with cirrhosis and ascites, fluid restriction is essential to prevent fluid overload, which can worsen symptoms of liver failure. Option A is incorrect because increasing fluid intake would exacerbate the issue of fluid overload. Option C, while important, is not the best initial response to the client's question about fluid restriction. Option D is incorrect as increasing dietary protein does not directly address fluid restriction in clients with cirrhosis and ascites.

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