Nursing Elites

1. What is the most appropriate nursing intervention for a patient experiencing hypoglycemia?

• A. Administer IV glucose
• B. Administer oral glucose
• C. Check blood sugar in 15 minutes
• D. Provide a high-calorie snack

Correct answer: B

Rationale: The most appropriate nursing intervention for a patient experiencing hypoglycemia is to administer oral glucose. Oral glucose is usually sufficient for treating mild hypoglycemia and can be administered quickly and easily. Administering IV glucose (Choice A) is reserved for severe cases where the patient is unable to swallow or unconscious. Checking blood sugar in 15 minutes (Choice C) is important but providing glucose should come first. Providing a high-calorie snack (Choice D) may not be as rapidly effective as administering oral glucose in quickly raising blood sugar levels in a patient experiencing hypoglycemia.

2. A nurse is caring for a client who is 2 hours postoperative following a thoracotomy. Which of the following findings should the nurse report to the provider?

• A. Chest tube drainage of 60 mL/hr
• B. Oxygen saturation of 95%
• C. Chest tube drainage of 120 mL/hr
• D. Heart rate of 88/min

Correct answer: C

Rationale: The correct answer is C. Chest tube drainage of more than 100 mL/hr may indicate active bleeding, which is a serious complication post-thoracotomy surgery. This finding should be reported to the healthcare provider immediately for further evaluation and intervention. Choices A, B, and D are within normal limits for a client 2 hours post-thoracotomy and do not require immediate reporting. Oxygen saturation of 95% is acceptable, and a heart rate of 88/min is within the normal range for an adult.

3. A nurse is caring for a client who is 4 hours postoperative following an open cholecystectomy. Which of the following actions should the nurse take?

• A. Monitor the client's urinary output.
• B. Assist the client to splint the incision with a pillow when coughing.
• C. Provide the client with a clear liquid diet.
• D. Encourage the client to ambulate in the hallway.

Correct answer: B

Rationale: Assisting the client to splint the incision with a pillow while coughing is the correct action in this scenario. This intervention helps reduce pain and prevent wound dehiscence, which is the partial or complete separation of the layers of a surgical wound. Monitoring urinary output is important but not the priority at this immediate postoperative stage. Providing a clear liquid diet may be indicated later but is not the most immediate concern. Encouraging ambulation is beneficial for preventing complications like deep vein thrombosis, but splinting the incision is more crucial at this early postoperative period.

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

• A. Take this medication at bedtime.
• B. Take your pulse before taking this medication.
• C. Avoid eating foods high in potassium.
• D. Take this medication with an antacid.

Correct answer: B

Rationale: The correct instruction for the nurse to include is to advise the client to take their pulse before taking digoxin. This is important to monitor for bradycardia, a potential side effect of the medication. Option A is incorrect because digoxin is usually taken in the morning. Option C is unrelated to digoxin therapy, as high potassium foods are usually restricted in clients taking potassium-sparing diuretics. Option D is incorrect because digoxin should not be taken with antacids as they can affect its absorption.

5. A nurse is assessing a client who has deep vein thrombosis (DVT) in the left lower extremity. Which of the following findings should the nurse expect?

• A. Pain in the right lower extremity
• B. Cold skin in the affected extremity
• C. Redness and warmth in the affected extremity
• D. Shiny skin on the affected extremity

Correct answer: C

Rationale: Corrected Rationale: Redness and warmth are classic signs of inflammation, which are commonly seen in clients with deep vein thrombosis (DVT). These findings indicate increased blood flow and temperature in the affected area. Pain in the right lower extremity (Choice A) is not expected in a client with DVT affecting the left lower extremity. Cold skin (Choice B) is not a typical finding in DVT; instead, warmth is more indicative of inflammation. Shiny skin (Choice D) is not a common characteristic of DVT; rather, the skin may appear red, swollen, and warm due to the inflammatory process.

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