Nursing Elites

1. What is the best intervention for a patient experiencing severe hypoglycemia?

• A. Administer IV dextrose
• B. Administer oral glucose
• C. Monitor blood sugar levels
• D. Recheck blood sugar in 15 minutes

Correct answer: A

Rationale: The best intervention for a patient experiencing severe hypoglycemia is to administer IV dextrose. This intervention is necessary to rapidly raise blood sugar levels in critical situations. Administering oral glucose may not be effective in severe cases as the patient may be unable to consume it. Monitoring blood sugar levels and rechecking blood sugar in 15 minutes are important steps but not the initial best intervention for severe hypoglycemia.

2. A nurse is providing discharge teaching to a client who has a new prescription for warfarin. Which of the following instructions should the nurse include?

• A. You should avoid consuming foods high in vitamin K.
• B. Take this medication at the same time each day.
• C. Monitor for signs of bruising and bleeding.
• D. Have your INR checked every 4 weeks.

Correct answer: A

Rationale: The correct instruction the nurse should include is to advise the client to avoid consuming foods high in vitamin K. Foods rich in vitamin K, such as leafy greens, can interfere with the effectiveness of warfarin, an anticoagulant medication. Therefore, it is important for clients on warfarin therapy to maintain consistent vitamin K intake to keep their INR levels stable. The other options are also important but not the priority in the context of warfarin therapy. Ingesting foods high in vitamin K can affect the medication's efficacy, making it crucial to highlight this dietary consideration during client education.

3. A nurse is preparing to measure the temperature of an infant. Which of the following actions should the nurse take?

• A. Place the tip of the thermometer under the center of the infant's axilla.
• B. Pull the pinna of the infant's ear forward before inserting the probe.
• C. Insert the probe 3.8 cm (1.5 inches) into the infant's rectum.
• D. Insert the thermometer in front of the infant's tongue.

Correct answer: A

Rationale: The correct method for measuring an infant's temperature is by placing the tip of the thermometer under the center of the infant's axilla (armpit). This method is non-invasive and safe. Pulling the pinna of the ear forward is used when taking a tympanic temperature. Inserting the probe into the rectum is done for rectal temperature measurement, which is not recommended as an initial method in infants. Inserting the thermometer in front of the infant's tongue is not a standard method for measuring temperature in infants.

4. A nurse is planning care for a client who has a prescription for a bowel-training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care?

• A. Encourage a maximum fluid intake of 1,500 ml per day.
• B. Increase the intake of refined grains in the client's diet.
• C. Provide the client with a cold drink prior to defecation.
• D. Administer a rectal suppository 30 minutes prior to scheduled defecation times.

Correct answer: D

Rationale: Administering a rectal suppository 30 minutes before scheduled defecation times is essential in a bowel-training program following a spinal cord injury. The suppository helps stimulate bowel movements and aids in establishing a regular bowel routine. Encouraging a maximum fluid intake of 1,500 ml per day (Choice A) might be beneficial for bowel function, but it is not specific to the bowel-training program. Increasing the intake of refined grains in the diet (Choice B) is not necessary and could potentially lead to constipation rather than improving bowel movements. Providing a cold drink prior to defecation (Choice C) may not directly contribute to the effectiveness of the bowel-training program compared to the use of a rectal suppository.

5. A client has a new prescription for digoxin. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime to prevent nausea.
• B. Take this medication with a full glass of milk.
• C. Notify your provider if you experience visual disturbances.
• D. Report any muscle pain to your provider.

Correct answer: C

Rationale: The correct answer is C: 'Notify your provider if you experience visual disturbances.' Visual disturbances can indicate digoxin toxicity, so it is essential for clients taking digoxin to report any changes in vision to their healthcare provider. Option A is incorrect because the timing of digoxin administration is crucial, usually in the morning. Option B is inaccurate because digoxin should not be taken with milk as it can affect its absorption. Option D is not directly associated with digoxin use and should not be the priority instruction for a client on this medication.

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