Nursing Elites

1. What are the early signs of hypoglycemia in a diabetic patient?

• A. Sweating and trembling
• B. Confusion and irritability
• C. Dizziness and increased heart rate
• D. Nausea and vomiting

Correct answer: A

Rationale: The correct answer is A: 'Sweating and trembling.' These are classic early signs of hypoglycemia in a diabetic patient. Sweating occurs due to the activation of the sympathetic nervous system in response to low blood sugar levels, while trembling is a result of the body's attempt to increase muscle activity to raise blood sugar levels. Confusion and irritability (Choice B) are more advanced signs of hypoglycemia that occur if the condition is not treated promptly. Dizziness and increased heart rate (Choice C) can also occur but are not as specific and early as sweating and trembling. Nausea and vomiting (Choice D) are more commonly associated with other conditions or severe hypoglycemia, rather than being early signs.

2. What is the most appropriate response when a client with chronic kidney disease asks about fluid restrictions?

• A. Fluid restrictions are not needed for all clients with chronic kidney disease.
• B. You may need to limit fluid intake to prevent fluid overload.
• C. Fluid restrictions are based on your lab results and daily weights.
• D. Restricting fluids is only necessary during dialysis.

Correct answer: B

Rationale: The most appropriate response when a client with chronic kidney disease asks about fluid restrictions is to inform them that limiting fluid intake may be necessary to prevent fluid overload. This is crucial in managing the condition and preventing complications such as edema and electrolyte imbalances. Choice A is incorrect as fluid restrictions are commonly advised for clients with chronic kidney disease. Choice C is partially correct as fluid restrictions are indeed based on lab results and daily weights, but the primary goal is to prevent fluid overload. Choice D is incorrect because fluid restrictions are not limited to just during dialysis; they are often recommended throughout the day to manage the condition.

3. A nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following actions should the nurse take?

• A. Administer the TPN through a peripheral IV catheter.
• B. Check the client's capillary blood glucose level every 4 hours.
• C. Heat the TPN solution to room temperature before administering.
• D. Weigh the client every 3 days.

Correct answer: B

Rationale: The correct answer is to check the client's capillary blood glucose level every 4 hours. Clients receiving TPN are at risk for hyperglycemia, so regular monitoring of blood glucose levels is essential to detect and manage hyperglycemia promptly. Administering TPN through a peripheral IV catheter (Choice A) is incorrect as TPN should be given through a central venous catheter to prevent complications. Heating the TPN solution to room temperature (Choice C) is unnecessary and not a standard practice. Weighing the client every 3 days (Choice D) is important for monitoring fluid status but is not the priority action when caring for a client receiving TPN.

4. A nurse is caring for a client with a pressure ulcer and a serum albumin level of 3 g/dL. What should the nurse do first?

• A. Increase the client's protein intake
• B. Consult with a dietitian to improve the client's nutritional status
• C. Administer a protein supplement
• D. Monitor the client's fluid and electrolyte balance

Correct answer: B

Rationale: Consulting with a dietitian is the priority as it ensures that the client receives a comprehensive nutritional assessment and an individualized plan to address the low serum albumin level and pressure ulcer. Increasing protein intake (choice A) and administering a protein supplement (choice C) may be part of the dietitian's recommendations but should not be done without proper assessment and guidance. Monitoring fluid and electrolyte balance (choice D) is important but not the first step in addressing the client's nutritional needs.

5. A healthcare provider is assessing a client who has received a preoperative dose of morphine. Which of the following findings is the priority to report to the provider?

• A. Client reports nausea.
• B. Urinary output of 20 mL/hr.
• C. Oxygen saturation 90%.
• D. Respiratory rate 14/min.

Correct answer: C

Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice D) is within the normal range and does not suggest immediate danger.

Similar Questions