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 client with type 1 DM has a finger stick glucose level of 258mg/dl at bedtime. An order for sliding scale insulin exists. The nurse should:

• A. Call the physician
• B. Encourage the intake of fluids
• C. Administer the insulin as ordered
• D. Give the client ½ cup of orange juice

Correct answer: C

Rationale: In this scenario, the client with type 1 DM has a high glucose level at bedtime. The appropriate action for the nurse is to administer the sliding scale insulin as ordered. This insulin regimen is specifically designed to manage high blood glucose levels. Calling the physician is not necessary as the protocol for sliding scale insulin is already in place. Encouraging fluid intake or providing orange juice is not the correct intervention for addressing high blood glucose levels in this case.

3. The wound irrigation process cleanses the wound and:

• A. Reduces the potential pain in the wound region or area.
• B. Stops the spread of infection by creating a 'clean' area.
• C. Pushes extravasated blood from a hematoma into nearby healthy tissue.
• D. Allows for the introduction of medications in solution form.

Correct answer: D

Rationale: The correct answer is D because wound irrigation allows for the introduction of medications in solution form to the wound site. Choice A is incorrect because while wound irrigation can help with pain management indirectly by promoting healing, its primary purpose is not to reduce pain directly. Choice B is incorrect as wound irrigation primarily aims to cleanse the wound and remove contaminants rather than creating a 'clean' area to stop infection spread. Choice C is incorrect because wound irrigation does not involve pushing extravasated blood from a hematoma into nearby healthy tissue; its main goal is to cleanse the wound and promote healing.

4. A nurse is assessing a client who is postoperative following a left leg below-the-knee amputation. Which of the following client statements indicates the potential need for a referral to an occupational therapist?

• A. I hope I can adjust to using crutches while I am recovering.
• B. I am worried about taking care of my toddler at home.
• C. I just don't think I can handle looking at my leg.
• D. I am not sure how I will pay for all the therapy I will need.

Correct answer: A

Rationale: The client's statement about adjusting to using crutches while recovering suggests a potential need for occupational therapy referral. Occupational therapists assist individuals in regaining independence in activities of daily living, including mobility aids and adaptations. Choices B, C, and D are more indicative of emotional or financial concerns and may require referrals to other healthcare professionals like counselors or financial advisors, rather than occupational therapists.

5. What is the main purpose of quality improvement in healthcare?

• A. To increase healthcare costs
• B. To improve patient outcomes
• C. To decrease patient satisfaction
• D. To increase hospital stays

Correct answer: B

Rationale: The main purpose of quality improvement in healthcare is to improve patient outcomes by enhancing the quality and safety of healthcare services. Choice A is incorrect because the goal is not to increase healthcare costs but to optimize resources and provide cost-effective care. Choice C is incorrect as the aim is to increase patient satisfaction through better outcomes. Choice D is incorrect as the objective is to reduce hospital stays by improving care efficiency and effectiveness.

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