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 in a long-term care facility is observing a newly licensed nurse who is providing tracheostomy care for a client. The nurse identifies proper performance of the procedure when the newly licensed nurse selects which of the following solutions to clean the inner cannula?

• A. Normal saline
• B. Hydrogen peroxide
• C. Iodine
• D. Alcohol

Correct answer: B

Rationale: The correct answer is B: Hydrogen peroxide. Hydrogen peroxide is commonly used to clean tracheostomy cannulas to prevent infection. Normal saline (choice A) is used for wound irrigation but not for cleaning inner cannulas of tracheostomy tubes. Iodine (choice C) and alcohol (choice D) are not recommended for cleaning tracheostomy cannulas as they can be too harsh and irritating to the delicate tissues of the airway.

3. A nurse offers pain meds to a client who is postop prior to ambulation. The nurse understands that this aspect of care delivery is an example of which of the following ethical principles?

• A. Fidelity
• B. Autonomy
• C. Justice
• D. Beneficence

Correct answer: D

Rationale: In this scenario, offering pain medication to a postoperative client before ambulation is an example of beneficence. Beneficence is the ethical principle related to promoting the well-being of the client, which includes providing pain relief to improve the client's comfort and facilitate their recovery. Fidelity (choice A) is about honoring commitments and being faithful to agreements, not directly related to pain management. Autonomy (choice B) refers to respecting the client's right to make decisions about their care, not specifically about pain medication administration. Justice (choice C) involves fairness and equality in healthcare resource allocation, not directly applicable in this situation.

4. A client is receiving phenytoin for management of grand mal seizures and has a new prescription for isoniazid and rifampin. Which of the following should the nurse conclude if the client develops ataxia and incoordination?

• A. The client is experiencing an adverse reaction to rifampin.
• B. The client's seizure disorder is no longer under control.
• C. The client is showing evidence of phenytoin toxicity.
• D. The client is having adverse effects due to combination antimicrobial therapy.

Correct answer: C

Rationale: Ataxia and incoordination are signs of phenytoin toxicity rather than adverse reactions to rifampin or isoniazid. These symptoms indicate that the client is experiencing an adverse effect of phenytoin, requiring a dose adjustment. Choice A is incorrect because rifampin is not typically associated with ataxia and incoordination. Choice B is incorrect as the development of ataxia and incoordination does not necessarily mean the seizure disorder is no longer under control. Choice D is incorrect as the symptoms are more indicative of phenytoin toxicity rather than adverse effects of combination antimicrobial therapy.

5. What is the role of the nurse in postoperative care for a patient with a hip replacement?

• A. Monitor for signs of infection and administer pain relief
• B. Ensure the patient follows a low-calcium diet
• C. Ensure the patient uses crutches to avoid pressure on the hip
• D. Monitor for signs of deep vein thrombosis

Correct answer: A

Rationale: The correct answer is A: Monitor for signs of infection and administer pain relief. In postoperative care for a patient with a hip replacement, it is crucial for the nurse to monitor for signs of infection, such as increased pain, redness, swelling, or drainage from the surgical site. Administering pain relief is also important to ensure the patient's comfort and aid in their recovery. Choices B, C, and D are incorrect as they do not directly relate to the immediate postoperative care needs of a patient with a hip replacement. Ensuring a low-calcium diet, using crutches, or monitoring for deep vein thrombosis are not primary responsibilities in the immediate postoperative period for this type of surgery.

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