Nursing Elites

1. Which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide (DiaBeta)?

• A. Administer glyburide again
• B. Administer subcutaneous insulin and monitor blood glucose
• C. Monitor blood glucose closely, and look for signs of hypoglycemia
• D. Monitor blood glucose and assess for signs of hyperglycemia

Correct answer: C

Rationale: After a client complains of nausea and vomits one hour after taking glyburide, the priority nursing intervention should be to monitor blood glucose closely and look for signs of hypoglycemia. Vomiting could indicate that the glyburide was not properly absorbed, potentially leading to hypoglycemia. Administering glyburide again (Choice A) could worsen hypoglycemia. Administering subcutaneous insulin (Choice B) is not appropriate without assessing the blood glucose first. Monitoring for signs of hyperglycemia (Choice D) is not the immediate concern in this situation.

2. A nurse reviews the electrolyte results of an assigned client and notes that the potassium level is 5.4 mEq/L. Which of the following would the nurse expect to note on the electrocardiogram as a result of the laboratory value?

• A. ST depression
• B. Inverted T wave
• C. Prominent U wave
• D. Tall peaked T waves

Correct answer: D

Rationale: The correct answer is 'Tall peaked T waves.' Tall peaked T waves are characteristic ECG changes associated with hyperkalemia. In hyperkalemia, the elevated potassium levels affect the myocardium, leading to changes in the ECG. ST depression (Choice A) is more commonly associated with myocardial ischemia or infarction. Inverted T wave (Choice B) is seen in conditions like myocardial ischemia or CNS events. Prominent U wave (Choice C) is typically associated with hypokalemia or certain medications. Therefore, in this scenario, the nurse would expect to note tall peaked T waves on the electrocardiogram due to the elevated potassium level.

3. Which individual is most at risk for Osgood-Schlatter disease?

• A. An elderly female who is hospitalized with a hip fracture and on bed rest
• B. A middle-aged male patient who has been exposed to asbestos in the shipping industry
• C. An adolescent who is physically active and the captain of their soccer team
• D. An infant of low birth weight and a gestational age of 28 weeks

Correct answer: C

Rationale: Osgood-Schlatter disease is a condition that commonly affects adolescents who are physically active, especially during growth spurts. It is caused by overuse of the knee, leading to inflammation of the patellar ligament at the tibial tuberosity. The repetitive stress on the growth plate during activities like running and jumping can trigger this condition. Therefore, an adolescent who is physically active and the captain of their soccer team is most at risk for Osgood-Schlatter disease. Choices A, B, and D are not at high risk for this condition as it is primarily seen in active adolescents.

4. Alcohol, caffeine, or drugs are high-risk factors that all fall under which broad classification of risk factors?

• A. Social demographic
• B. Environmental
• C. Biophysical
• D. Psychosocial

Correct answer: D

Rationale: The correct answer is D: Psychosocial. Alcohol, caffeine, or drug use are considered psychosocial risk factors as they are related to individual behavior, lifestyle choices, and social interactions. Choices A, B, and C are incorrect. Social demographic factors (choice A) refer to characteristics of a population such as age, gender, education, income, etc. Environmental factors (choice B) include physical surroundings like air quality, housing conditions, etc. Biophysical factors (choice C) involve biological aspects like genetics, physiology, and health conditions.

5. Which of the following is expected to be most likely true in the near future?

• A. Quality improvement projects will decline due to cost-cutting measures.
• B. Alternative and complementary approaches will gain acceptance in medical practice.
• C. Care will primarily shift away from the hospital setting.
• D. Increased focus on care transitions will involve nursing.

Correct answer: D

Rationale: In the near future, there will be an increased focus on care transitions involving nursing. This means that nurses will play a crucial role in preparing patients for transitions between different care settings, ensuring continuity and quality of care. Choice A is incorrect because quality improvement projects are essential and are not expected to decline. Choice B is incorrect as alternative and complementary approaches are increasingly being integrated into medical practice. Choice C is incorrect as there is a growing trend towards providing care in community settings and homes, moving away from primarily hospital-based care.

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