Nursing Elites

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

• A. Administer glucagon
• B. Provide a source of glucose
• C. Monitor blood sugar
• D. Assess vital signs

Correct answer: A

Rationale: Administering glucagon is the recommended intervention for severe hypoglycemia, especially when the patient is unconscious or unable to consume oral glucose. Glucagon helps increase blood glucose levels rapidly by stimulating the release of stored glucose from the liver. Providing a source of glucose (Choice B) can be challenging if the patient is unable to swallow or unconscious, making glucagon a more effective option. Monitoring blood sugar levels (Choice C) and assessing vital signs (Choice D) are important aspects of managing hypoglycemia but are not the immediate intervention for severe cases where prompt elevation of blood glucose levels is necessary.

2. A nurse is caring for a client with dementia who frequently attempts to get out of bed unsupervised. What is the best intervention?

• A. Use restraints to prevent the client from getting out of bed
• B. Encourage family members to stay with the client at all times
• C. Use a bed exit alarm system
• D. Keep the client's room dark and quiet to reduce stimulation

Correct answer: C

Rationale: The best intervention for a client with dementia who frequently attempts to get out of bed unsupervised is to use a bed exit alarm system (Choice C). A bed exit alarm can alert staff when the client tries to leave the bed, helping to prevent falls. Using restraints (Choice A) is not recommended as it can lead to physical and psychological harm. While having family members present (Choice B) can be beneficial, it may not be feasible at all times. Keeping the client's room dark and quiet (Choice D) may not address the immediate safety concern of the client attempting to get out of bed.

3. A nurse is performing postmortem care for a client prior to the arrival of the client's family for viewing of the body. Which of the following actions should the nurse take?

• A. Apply moisturizing lotion to the skin
• B. Turn off the lights
• C. Remove all jewelry
• D. Gently close the client's eyelids

Correct answer: D

Rationale: The correct action the nurse should take is to gently close the client's eyelids. This is a respectful and common practice in postmortem care before allowing the family to view the body. Applying moisturizing lotion to the skin is unnecessary and may not be appropriate at this time. Turning off the lights might not be necessary and could impact the viewing environment for the family. While removing all jewelry is generally a good practice, it is not as crucial as gently closing the client's eyelids for postmortem care.

4. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following actions should the nurse take?

• A. Administer insulin
• B. Administer glucagon
• C. Administer 4 oz of orange juice
• D. Administer 1 L of water

Correct answer: C

Rationale: Administering 4 oz of orange juice is the appropriate action for a client experiencing hypoglycemia due to diabetes mellitus. Orange juice contains simple sugars that can quickly raise blood glucose levels. Insulin (Choice A) would further lower blood sugar, worsening the condition. Glucagon (Choice B) is used in severe hypoglycemia when the client cannot take anything by mouth. Administering 1 L of water (Choice D) is not indicated in hypoglycemia treatment; the priority is to raise blood sugar levels. Therefore, the correct choice is to administer orange juice to address the low blood sugar in this situation.

5. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?

• A. Educate the client about their current medical diagnosis.
• B. Refer the client to a meal delivery program.
• C. Identify environmental hazards in the home.
• D. Arrange transportation for the client to follow-up appointments.

Correct answer: C

Rationale: Identifying environmental hazards in the client's home is the priority during the initial visit with an older adult living alone. This action is crucial to prevent accidents, falls, and ensure the client's safety. While educating the client about their medical diagnosis, referring them to a meal delivery program, and arranging transportation for follow-up appointments are essential, addressing environmental hazards takes precedence as it directly impacts the client's immediate safety and well-being.

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