Nursing Elites

1. A client who took a camping vacation two weeks ago in a country with a tropical climate comes to the clinic describing vague symptoms and diarrhea for the past week. Which finding is most important for the nurse to report to the HCP?

• A. Weakness and fatigue
• B. Intestinal cramping
• C. Weight loss
• D. Jaundiced sclera

Correct answer: D

Rationale: The most important finding to report to the healthcare provider is a jaundiced sclera. Jaundice suggests liver involvement, which can be a sign of a serious underlying condition. Weakness and fatigue, intestinal cramping, and weight loss are important symptoms, but jaundice indicates a more urgent issue that needs immediate attention.

2. A client with hyperthyroidism is prescribed methimazole. Which adverse effect should the nurse monitor for?

• A. Agranulocytosis
• B. Hypoglycemia
• C. Bradycardia
• D. Hypercalcemia

Correct answer: A

Rationale: The correct answer is Agranulocytosis. Methimazole, used to treat hyperthyroidism, can lead to agranulocytosis, a severe decrease in white blood cells. This condition increases the risk of infections and requires immediate medical attention. Hypoglycemia (choice B) is not a common adverse effect of methimazole. Bradycardia (choice C) is unlikely as methimazole tends to have minimal effects on heart rate. Hypercalcemia (choice D) is not associated with methimazole use.

3. An overweight, young adult male who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply)

• A. Check his fingerstick glucose
• B. Assess his skin temperature and moisture
• C. Measure his pulse and BP
• D. All of the Above

Correct answer: D

Rationale: In this scenario, the patient is a young adult male with type 2 diabetes mellitus admitted for a hernia repair who is experiencing weakness and jitteriness. Checking his fingerstick glucose is crucial to assess his blood sugar levels, which can directly impact his symptoms. Assessing his skin temperature and moisture is important to evaluate his peripheral circulation and hydration status. Measuring his pulse and blood pressure helps in gauging his cardiovascular status. Therefore, all the actions mentioned in choices A, B, and C are appropriate for the nurse to implement in this situation to identify the underlying cause of the patient's symptoms. Choice D, 'All of the Above,' is the correct answer because all these actions are necessary for a comprehensive assessment of the patient's condition. Choices A, B, and C are incorrect individually as they each address different aspects of the patient's condition, and a holistic approach is needed to provide optimal care in this situation.

4. A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The HCP prescribes an NG tube to be inserted and placed on intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?

• A. Soak the NG tube in warm water
• B. Insert the tube with the client's head tilted back
• C. Apply suction while inserting the tube
• D. Elevate the head of the bed 60 to 90 degrees

Correct answer: D

Rationale: Elevating the head of the bed 60 to 90 degrees is the correct intervention to facilitate proper placement of the NG tube. This position helps to use gravity to guide the tube smoothly into the gastrointestinal tract. Soaking the NG tube in warm water (Choice A) is not necessary for proper placement. Inserting the tube with the client's head tilted back (Choice B) can cause discomfort and may lead to improper placement. Applying suction while inserting the tube (Choice C) is not recommended as it can cause trauma to the nasal passages and esophagus.

5. A client with diabetes mellitus presents with confusion and diaphoresis. What is the priority nursing action?

• A. Check the blood glucose level
• B. Administer insulin immediately
• C. Offer a high-protein snack
• D. Place the client in a supine position

Correct answer: A

Rationale: The correct answer is to check the blood glucose level. In a client with diabetes mellitus presenting with confusion and diaphoresis, it is important to assess the blood glucose level first to determine if the symptoms are due to hypoglycemia. Administering insulin immediately (Choice B) without knowing the blood glucose level can worsen the condition if the client is hypoglycemic. Offering a high-protein snack (Choice C) is not appropriate as the severity of hypoglycemia is unknown, and placing the client in a supine position (Choice D) is not the priority action for these symptoms.

Similar Questions