Nursing Elites

1. What should a healthcare provider monitor for in a patient with HIV and a CD4 T-cell count below 180 cells/mm3?

• A. Monitor for signs of infection
• B. Monitor for anemia
• C. Monitor for dehydration
• D. Monitor for bleeding

Correct answer: A

Rationale: A CD4 T-cell count below 180 cells/mm3 indicates severe immunocompromise in a patient with HIV. Monitoring for signs of infection is crucial because the patient is at high risk of developing opportunistic infections. Anemia (choice B), dehydration (choice C), and bleeding (choice D) are not directly associated with a low CD4 T-cell count in patients with HIV.

2. A nurse is teaching a client who has type 1 DM about hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

• A. Exercise reduces the risk for hypoglycemia.
• B. I can skip my insulin when I don't eat.
• C. I can drink 4 oz of soda if my blood sugar is low.
• D. Diabetic pills don't cause hypoglycemia; only insulin does.

Correct answer: C

Rationale: The client can correct any development of hypoglycemia with a quick intake of glucose. The client should have 15 g carbohydrates on hand to treat hypoglycemic episodes, like 4 oz of regular soda.

3. What is the priority action when a healthcare professional misreads a glucose reading and administers excess insulin?

• A. Administer IV glucose
• B. Monitor for hyperglycemia
• C. Monitor for hypoglycemia
• D. Document the incident

Correct answer: C

Rationale: The priority action when a healthcare professional misreads a glucose reading and administers excess insulin is to monitor for hypoglycemia. Excess insulin can lead to dangerously low blood sugar levels (hypoglycemia), which can result in serious complications. Monitoring for hypoglycemia allows for timely identification and intervention to prevent harm. Administering IV glucose may be necessary if hypoglycemia occurs. Monitoring for hyperglycemia is not the priority in this situation, as excess insulin would lower blood sugar levels. Documenting the incident is important for reporting and quality improvement purposes but should not take precedence over ensuring patient safety by monitoring for hypoglycemia.

4. A nurse is teaching a client about using a continuous positive airway pressure (CPAP) device to treat obstructive sleep apnea. Which of the following information should the nurse include in the teaching?

• A. It delivers a preset amount of inspiratory pressure throughout the breathing cycle
• B. It has a continuous adjustment feature that changes the airway pressure throughout the cycle
• C. It delivers a preset amount of airway pressure throughout the breathing cycle
• D. It delivers positive pressure at the end of each breath

Correct answer: C

Rationale: The correct answer is C because a CPAP device delivers a preset amount of positive airway pressure continuously throughout all inspiration and expiration cycles. Choice A is incorrect because CPAP does not deliver inspiratory pressure at the beginning of each breath; it provides continuous positive pressure. Choice B is incorrect because CPAP typically delivers a constant pressure rather than having a feature that changes pressure throughout the cycle. Choice D is incorrect as CPAP does not deliver positive pressure specifically at the end of each breath; it maintains a consistent pressure throughout the breathing cycle.

5. A patient reports abdominal cramping after enema administration. What action should the nurse take to relieve the discomfort?

• A. Lower the height of the solution container
• B. Increase the flow of enema solution
• C. Remove the enema tubing
• D. Stop the procedure

Correct answer: A

Rationale: The correct action to relieve abdominal cramping after enema administration is to lower the height of the solution container. This adjustment slows down the flow rate of the enema solution, which can help reduce discomfort by decreasing the pressure on the patient's abdomen. Increasing the flow of the enema solution (Choice B) would exacerbate the cramping by introducing more solution quickly. Removing the enema tubing (Choice C) is not necessary to address the cramping, and stopping the procedure (Choice D) may not be needed if adjusting the height of the solution container can resolve the issue.

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