Nursing Elites

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

• A. Administer glucagon
• B. Provide oral glucose
• C. Administer IV fluids
• D. Monitor blood sugar levels

Correct answer: B

Rationale: Providing oral glucose is the correct intervention for a patient experiencing hypoglycemia. Oral glucose helps quickly raise blood sugar levels, making it the preferred treatment for mild hypoglycemia. Administering glucagon (Choice A) is usually reserved for severe cases when the patient cannot take anything by mouth. Administering IV fluids (Choice C) is not the primary intervention for hypoglycemia unless the patient is severely dehydrated. Monitoring blood sugar levels (Choice D) is important but providing glucose is the immediate priority to treat hypoglycemia.

2. A nurse is preparing to assess a 2-week-old newborn. Which of the following actions should the nurse plan to take?

• A. Obtain the newborn's body temperature using a tympanic thermometer
• B. Pull the pinna of the infant's ear forward before inserting the probe
• C. Auscultate the newborn's apical pulse for 60 seconds
• D. Measure the newborn's head circumference over the eyebrows and below the occipital prominence

Correct answer: C

Rationale: The correct answer is C: Auscultate the newborn's apical pulse for 60 seconds. When assessing a newborn, it is essential to auscultate the apical pulse for a full 60 seconds to accurately determine their heart rate. This method allows for a more precise measurement, considering the variability in heart rates in newborns. Choice A is incorrect because tympanic thermometers are not typically used for newborns due to their ear canals being small and not fully developed. Choice B is incorrect as pulling the pinna forward is not necessary for assessing the apical pulse. Choice D is incorrect as measuring head circumference involves a different assessment and is not relevant to determining the heart rate of a newborn.

3. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?

• A. Your baby needs an IV because she is not producing any tears
• B. Your baby needs an IV because her fontanels are bulging
• C. Your baby needs an IV because she is breathing slower than normal
• D. Your baby needs an IV because her heart rate is decreasing

Correct answer: A

Rationale: The correct answer is A. A lack of tear production is a sign of severe dehydration in infants, indicating the need for IV therapy. Option B, bulging fontanels, is a sign of increased intracranial pressure, not dehydration. Option C, breathing slower than normal, and Option D, decreasing heart rate, are not specific signs of severe dehydration that would indicate the need for IV therapy in this case.

4. A client is postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 90/min
• B. Temperature of 37.1°C (98.8°F)
• C. Serosanguineous wound drainage
• D. Urine output of 25 mL/hr

Correct answer: D

Rationale: A urine output of 25 mL/hr is a sign of oliguria, which may indicate dehydration or kidney impairment and should be reported. A heart rate of 90/min is within the normal range (60-100/min) for adults at rest and may be expected postoperatively. A temperature of 37.1°C (98.8°F) is within the normal range (36.1-37.2°C or 97-99°F) and does not indicate an immediate concern. Serosanguineous wound drainage is a common finding postoperatively and indicates a normal healing process.

5. A nurse is caring for a client who has a pulmonary embolism. Which of the following findings indicates the effectiveness of the treatment?

• A. A chest x-ray reveals increased density in all lung fields.
• B. The client reports feeling less anxious.
• C. Diminished breath sounds are auscultated bilaterally.
• D. ABG results include pH 7.48, PaO2 77 mm Hg, and PaCO2 47 mm Hg.

Correct answer: B

Rationale: The correct answer is B. In a client with a pulmonary embolism, improvement in anxiety levels can indicate the effectiveness of treatment as it suggests better oxygenation and perfusion. Choices A, C, and D do not directly reflect the effectiveness of treatment for a pulmonary embolism. Increased density in all lung fields on a chest x-ray may indicate worsening of the condition, diminished breath sounds suggest impaired lung function, and ABG results with a pH of 7.48, PaO2 of 77 mm Hg, and PaCO2 of 47 mm Hg do not specifically indicate treatment effectiveness for a pulmonary embolism.

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