Nursing Elites

1. A client with amyotrophic lateral sclerosis (ALS) has been taking riluzole for two weeks. The nurse notes that the client remains weak with observable muscle atrophy. What action should the nurse take?

• A. Explain that the medication may take time to show improvement in symptoms
• B. Withhold the medication and notify the healthcare provider
• C. Advise the client to undergo liver function tests
• D. Document the assessment findings in the electronic health record

Correct answer: D

Rationale: In this scenario, the nurse's priority is to document the assessment findings in the electronic health record. This action is crucial for maintaining an accurate record of the client's health status and can provide valuable information for the healthcare team. While it is important to monitor the client's response to riluzole, explaining that the medication may take time to show improvement (Choice A) would be more appropriate if the client was expecting immediate results. Withholding the medication and notifying the healthcare provider (Choice B) should not be the initial action without further assessment or guidance. Advising the client to undergo liver function tests (Choice C) is not directly related to the current situation of weakness and muscle atrophy.

2. A client arrives at the emergency department experiencing diabetic ketoacidosis (DKA). The healthcare provider prescribes an insulin intravenous drip. Which type of insulin should the nurse locate for the registered nurse to mix into the intravenous fluids?

• A. Isophane
• B. Glargine
• C. Regular
• D. Detemir

Correct answer: C

Rationale: The correct insulin type for the nurse to mix into the intravenous fluids is regular insulin. In the scenario of diabetic ketoacidosis (DKA), rapid reduction of blood glucose levels is crucial. Regular insulin has a fast onset of action, making it suitable for intravenous administration to address the high blood sugar levels seen in DKA. Isophane, Glargine, and Detemir are not appropriate choices for intravenous administration in this emergency situation as they are intermediate-acting or long-acting insulins which do not provide the rapid response needed in DKA.

3. A client is prescribed an antacid for the treatment of peptic ulcer disease. What is the action of this medication that is effective in treating the client's ulcer?

• A. Decrease in the production of gastric secretions
• B. Production of an adherent barrier over the ulcer
• C. Maintenance of a gastric pH of 3.5 or above
• D. Decrease in the gastric motor activity

Correct answer: C

Rationale: The correct answer is C. Antacids work by neutralizing gastric acids and maintaining a gastric pH of 3.5 or above. This pH level is crucial to prevent the activation of pepsinogen, a precursor to pepsin, which can further damage the ulcer. Choice A is incorrect because antacids do not directly decrease the production of gastric secretions; they neutralize existing acid. Choice B is incorrect as antacids do not form a physical barrier over the ulcer but rather neutralize the acid around it. Choice D is also incorrect as antacids do not affect gastric motor activity but focus on reducing acidity in the stomach.

4. When planning to administer the antiulcer GI agent sucralfate, what instruction should the nurse provide regarding administration?

• A. Administer sucralfate once a day
• B. Assess for secondary candida infection
• C. Monitor electrolyte imbalance
• D. Give sucralfate on an empty stomach

Correct answer: D

Rationale: Sucralfate is most effective when taken on an empty stomach. This allows the medication to form a protective layer over the ulcer, promoting healing and symptom relief. Administering sucralfate with or after meals may reduce its efficacy as it may bind to food instead of coating the ulcer site.

5. When should a glucagon emergency kit be used for a client with Type 1 diabetes?

• A. During episodes of hypoglycemia
• B. At the onset of signs of diabetic ketoacidosis
• C. Before meals to prevent hyperglycemia
• D. When signs of severe hypoglycemia occur

Correct answer: D

Rationale: A glucagon emergency kit is used when signs of severe hypoglycemia occur in a client with Type 1 diabetes. Glucagon helps raise blood glucose levels in cases of severe hypoglycemia when the individual is unable to take oral glucose. It is crucial to administer glucagon promptly to prevent serious complications associated with low blood sugar levels. Choices A, B, and C are incorrect because a glucagon emergency kit is specifically indicated for severe hypoglycemia, not for general episodes of hypoglycemia, diabetic ketoacidosis, or prevention of hyperglycemia.

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