Nursing Elites

1. A client with a history of diabetes mellitus is admitted with hypoglycemia. Which finding requires immediate intervention?

• A. Blood glucose of 60 mg/dL.
• B. Heart rate of 100 beats per minute.
• C. Tremors.
• D. Diaphoresis.

Correct answer: C

Rationale: In a client with a history of diabetes mellitus admitted with hypoglycemia, the finding that requires immediate intervention is tremors. Tremors can indicate severe hypoglycemia, which needs prompt attention to prevent complications such as seizures or loss of consciousness. While a blood glucose level of 60 mg/dL is low, the presence of tremors signifies a more urgent situation. A heart rate of 100 beats per minute and diaphoresis are common physiological responses to hypoglycemia and do not necessarily require immediate intervention unless other severe symptoms are present.

2. A client with a head injury is admitted to the hospital. Which finding indicates a need for immediate intervention?

• A. Glasgow Coma Scale (GCS) score of 15.
• B. Pupils are equal and reactive to light.
• C. Client is drowsy but arousable.
• D. Client does not remember the events leading to the injury.

Correct answer: C

Rationale: In a client with a head injury, being drowsy but still arousable can be a sign of increased intracranial pressure, which necessitates immediate intervention. This presentation may indicate a deterioration in neurological status, requiring prompt assessment and management to prevent further complications. Choices A, B, and D are not indicative of an immediate need for intervention in this scenario. A Glasgow Coma Scale (GCS) score of 15 indicates the highest level of consciousness; pupils being equal and reactive to light suggest intact cranial nerve function, and memory loss about the injury event is common in head injuries and does not necessarily warrant immediate intervention.

3. A community health nurse is planning a program to reduce the incidence of heart disease in the community. Which intervention should the nurse prioritize?

• A. Distributing educational materials on heart-healthy diets
• B. Organizing free cholesterol screenings
• C. Holding workshops on stress management
• D. Partnering with local gyms to offer fitness classes

Correct answer: B

Rationale: The correct answer is B: Organizing free cholesterol screenings. This intervention is crucial because it helps identify individuals at risk for heart disease by assessing their cholesterol levels. High cholesterol is a significant risk factor for heart disease, and identifying it early can lead to timely interventions and medical care. Choices A, C, and D, while beneficial for overall health, may not directly address the specific risk factor of high cholesterol associated with heart disease. Distributing educational materials on heart-healthy diets (A) could be helpful in preventing heart disease, but identifying individuals already at risk is a more urgent need. Holding workshops on stress management (C) and partnering with local gyms for fitness classes (D) are important for overall health promotion but may not target the specific risk factor of high cholesterol as directly as organizing cholesterol screenings.

4. The healthcare provider is preparing to administer intravenous immune globulin (IVIG) to a client with Guillain-Barre syndrome. Which assessment is most important before initiating the infusion?

• A. Lung sounds and respiratory status.
• B. Skin integrity and color.
• C. Neurological status and level of consciousness.
• D. Cardiac rate and rhythm.

Correct answer: D

Rationale: The correct answer is D, "Cardiac rate and rhythm." Monitoring cardiac rate and rhythm is crucial before initiating IVIG because bradycardia is a common side effect associated with this therapy. Assessing lung sounds and respiratory status (Choice A) is important, but cardiac monitoring takes precedence due to the risk of bradycardia. Skin integrity and color (Choice B) are important assessments, but they are not directly related to potential complications of IVIG infusion. Neurological status and level of consciousness (Choice C) are also vital assessments, but monitoring cardiac function is more pertinent in this scenario.

5. The nurse is developing a series of childbirth preparation classes for primigravida women and their significant others. What is the priority expected outcome for these classes?

• A. Participants can identify at least three coping strategies to use during labor.
• B. Participants can list signs of labor and when to come to the hospital.
• C. Participants can describe three pain relief measures to use during labor.
• D. Participants can perform three relaxation techniques to use during labor.

Correct answer: A

Rationale: The priority expected outcome for childbirth preparation classes is for participants to be able to identify coping strategies to use during labor. This is crucial as coping strategies can help women manage pain, stress, and anxiety during childbirth. Choice B is important but does not focus on coping strategies needed during labor. Choice C is relevant but focuses solely on pain relief measures which are a part of coping strategies. Choice D is also relevant but does not encompass all aspects of coping with labor effectively.

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