Nursing Elites

1. Two days after an abdominal hysterectomy, an elderly female with diabetes has a syncopal episode. The nurse determines that her vital signs are within normal limits, but her blood sugar is 325 mg/dL or 18.04 mmol/L (SI). What intervention should the nurse implement first?

• A. Administer regular insulin per sliding scale
• B. Cancel the client's dinner tray
• C. Give the client 4 ounces (120 mL) of orange juice
• D. Administer the next scheduled dose of metformin

Correct answer: A

Rationale: In this case, the nurse should implement the intervention of administering regular insulin per sliding scale. High blood sugar levels, as indicated by a reading of 325 mg/dL, require insulin administration to prevent complications such as hyperglycemia. Canceling the client's dinner tray (choice B) would not address the immediate need to lower the blood sugar level. Giving the client orange juice (choice C) might further increase the blood sugar level as it contains sugar. Administering the next scheduled dose of metformin (choice D) is not appropriate as metformin is not typically used for acute management of high blood sugar levels.

2. A female client with breast cancer who completed her first chemotherapy treatment today at an outpatient center is preparing for discharge. Which behavior indicates that the client understands her care needs?

• A. Rented movies and borrowed books to use while passing time at home
• B. Discussing dietary restrictions with the nurse
• C. Arranging follow-up appointments with her oncologist
• D. Reporting to the nurse any new or worsening symptoms

Correct answer: D

Rationale: The correct answer is D because reporting any new or worsening symptoms to the nurse is crucial for the early detection of potential complications. This behavior shows that the client understands the importance of monitoring her health status post-chemotherapy treatment. Choices A, B, and C are incorrect because while renting movies, borrowing books, discussing dietary restrictions, and arranging follow-up appointments are all important aspects of care, the most critical factor immediately after chemotherapy is to monitor and report any new or worsening symptoms to healthcare providers.

3. During the administration of albuterol per nebulizer, the client complains of shakiness. The client’s vital signs are heart rate 120 beats/minute, respirations 20 breaths/minute, blood pressure 140/80. What action should the nurse take?

• A. Administer an anxiolytic
• B. Obtain a 12-lead electrocardiogram
• C. Stop the albuterol administration and restart in 30 minutes
• D. Educate the client about the side effects of albuterol

Correct answer: D

Rationale: Shakiness is a known side effect of albuterol, which can often be managed without the need for additional medications. Educating the client about the potential side effects of albuterol, including shakiness, helps them understand what to expect and how to manage these effects. Administering an anxiolytic (Choice A) is not indicated as shakiness related to albuterol is not a sign of anxiety. Obtaining a 12-lead electrocardiogram (Choice B) is not necessary based on the client's presentation of shakiness and vital signs. Stopping the albuterol administration and restarting in 30 minutes (Choice C) may not be necessary since shakiness is a common side effect that can often be managed without interrupting the treatment.

4. The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?

• A. Encourage the client's family to visit more often
• B. Schedule a daily conference with the social worker
• C. Encourage the client to participate in group activities
• D. Engage the client in a non-threatening conversation

Correct answer: D

Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.

5. A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric phase?

• A. RUQ abdominal pain
• B. Clay-colored stools
• C. Icteric sclera
• D. Pruritus

Correct answer: A

Rationale: During the preicteric phase of hepatitis A, the nurse should expect to find RUQ (right upper quadrant) abdominal pain. This pain is common in the early phase of hepatitis A and is associated with liver inflammation. Clay-colored stools (Choice B) are typically seen in the icteric phase when there is a lack of bile flow. Icteric sclera (Choice C) refers to yellowing of the eyes, which is a characteristic of the icteric phase. Pruritus (Choice D), which is itching of the skin, is also more commonly associated with the icteric phase when bile salts accumulate in the skin.

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