Nursing Elites

1. What are the complications of diabetes mellitus that a nurse should monitor for?

• A. Peripheral neuropathy and retinopathy
• B. All of the above
• C. Diabetic ketoacidosis and hyperosmolar hyperglycemic state
• D. Nephropathy and cardiovascular disease

Correct answer: D

Rationale: The correct answer is D. Complications of diabetes mellitus that a nurse should monitor for include nephropathy and cardiovascular disease, in addition to diabetic ketoacidosis, hyperosmolar hyperglycemic state, neuropathy, and retinopathy. While choices A and C mention some complications of diabetes, they do not cover all the complications that a nurse should monitor for. Choice B is incorrect as it suggests selecting all options, which is not accurate.

2. A nursing instructor is observing a nursing student practicing standard precautions. Which observation by the instructor indicates a need for further teaching?

• A. The nursing student wears a gown to change the bed of an incontinent client.
• B. The nursing student washes hands before making contact with the client.
• C. The nursing student washes her hands before glove removal after emptying a Foley bag.
• D. The nursing student changes gloves between tasks and procedures.

Correct answer: C

Rationale: The correct answer is C. The nursing student washing her hands before glove removal after emptying a Foley bag indicates a need for further teaching. Hands should be washed after glove removal to maintain proper infection control. Choice A is correct as wearing a gown when changing the bed of an incontinent client is a standard precaution. Choice B is correct as washing hands before making contact with the client is a good practice. Choice D is correct as changing gloves between tasks and procedures is a standard precaution to prevent the spread of infection.

3. Which of the following is a primary focus of tertiary prevention in mental health?

• A. Identifying early signs of mental illness
• B. Preventing the occurrence of mental health problems
• C. Rehabilitation and prevention of further deterioration
• D. Providing a safe environment to prevent harm

Correct answer: C

Rationale: The correct answer is C: Rehabilitation and prevention of further deterioration. Tertiary prevention in mental health aims to provide interventions and support to individuals who already have a mental illness to prevent further deterioration and promote recovery. Choice A, identifying early signs of mental illness, is more aligned with primary prevention which focuses on preventing the onset of mental health problems. Choice B, preventing the occurrence of mental health problems, pertains to secondary prevention which involves early detection and intervention to prevent the progression of mental health issues. Choice D, providing a safe environment to prevent harm, is important but it is not the primary focus of tertiary prevention which is more centered on rehabilitation and improving the quality of life for individuals with existing mental health conditions.

4. A nurse is preparing to administer enoxaparin subcutaneously to a client. Which of the following actions should the nurse take?

• A. Inject at a 90-degree angle
• B. Inject at a 45-degree angle
• C. Massage the injection site after administering
• D. Use a longer needle

Correct answer: B

Rationale: The correct answer is to inject enoxaparin subcutaneously at a 45-degree angle. This angle helps ensure proper delivery of the medication into the subcutaneous tissue. Option A (Inject at a 90-degree angle) is incorrect because subcutaneous injections are usually given at a shallower angle. Option C (Massage the injection site after administering) is incorrect as massaging the site can cause bruising and should generally be avoided. Option D (Use a longer needle) is incorrect as using a longer needle is unnecessary and may increase the risk of injecting the medication too deeply.

5. A patient has an ankle restraint applied. Upon assessment, the nurse finds the toes a light blue color. Which action will the nurse take next?

• A. Immediately do a complete head-to-toe neurological assessment.
• B. Take the patient's blood pressure, pulse, temperature, and respiratory rate.
• C. Place a blanket over the feet.
• D. Remove the restraint.

Correct answer: D

Rationale: The correct answer is to remove the restraint (Choice D). Cyanosis of the toes, indicated by a light blue color, suggests impaired circulation. The priority action is to ensure proper circulation by removing the restraint to prevent further compromise. Choices A and B are not the immediate actions needed for cyanosis related to impaired circulation. Choice C, placing a blanket over the feet, does not address the underlying issue of impaired circulation and could delay appropriate intervention.

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