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. The nurse is planning care for a patient with acute hypernatremia. What should the nurse include in this patient's plan of care? (select one that does not apply)

• A. Reduce IV access
• B. Limit length of visits
• C. Restrict fluids to 1500 mL per day
• D. Conduct frequent neurologic checks

Correct answer: D

Rationale: For a patient with acute hypernatremia, the nurse should include interventions like reducing free water losses, correcting sodium levels slowly, monitoring neurologic status, and ensuring adequate fluid intake. Conducting frequent neurologic checks is essential in assessing the patient's neurological status and detecting any changes promptly. Therefore, this action should not be excluded from the plan of care. Choices A, B, and C are not directly related to managing acute hypernatremia and can be safely excluded from the plan of care. Reducing IV access, limiting length of visits, and restricting fluids to 1500 mL per day are not appropriate actions for managing acute hypernatremia.

3. While administering penicillin intravenously, you notice that the patient becomes hypotensive with a bounding, rapid pulse rate. What is the first action you should take?

• A. Decrease the rate of the intravenous medication flow.
• B. Increase the rate of the intravenous medication flow.
• C. Call the doctor.
• D. Stop the intravenous flow.

Correct answer: D

Rationale: The correct action to take when a patient becomes hypotensive with a bounding, rapid pulse rate after administering penicillin intravenously is to stop the intravenous flow immediately. This can help prevent further complications by discontinuing the administration of the medication that might be causing the adverse effects. Decreasing or increasing the rate of medication flow may not address the underlying issue of the patient's adverse reaction. While it's important to involve the healthcare provider in such situations, the immediate priority is to halt the administration of the medication.

4. Who should document care?

• A. The LPNs should document the care that they provided and the care that was given by unlicensed assistive staff.
• B. The registered nurse must document all of the care that is provided by the nursing assistants because they are accountable for all care.
• C. All staff members should document all of the care that they have provided.
• D. All staff should document all of the care that they have provided but the registered nurse, as the only independent practitioner, signs it.

Correct answer: C

Rationale: All staff members should document the care they provided as part of their accountability and to ensure accurate and comprehensive records. In healthcare settings, it is essential for all staff to document the care they deliver for continuity of care and legal purposes. The registered nurse may sign off on the documentation for oversight purposes, but the responsibility of documenting care extends to all staff involved in patient care. Choices A and B incorrectly limit the responsibility to specific roles, while choice D inaccurately suggests that only the registered nurse signs off on the documentation, overlooking the importance of comprehensive documentation by all staff members involved.

5. A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?

• A. I will have a client who is on airborne precautions wear a mask when out of their room.
• B. I will wear an N95 respirator mask for a client who is on droplet precautions.
• C. I will place a client who has compromised immunity in a negative-pressure airflow room.
• D. I will instruct visitors to wear a mask when visiting a client who is on contact precautions.

Correct answer: A

Rationale: The correct answer is A. Having a client on airborne precautions wear a mask when out of their room is appropriate to prevent the spread of infection. Choice B is incorrect because the healthcare provider, not the client, wears an N95 respirator mask for a client on droplet precautions. Choice C is incorrect because negative-pressure airflow rooms are used for clients with airborne infections, not compromised immunity. Choice D is incorrect because visitors, not clients, should wear a mask when visiting a client on contact precautions.

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