Nursing Elites

1. A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat:

• A. Within 10 to 15 minutes after the injection.
• B. 1 hour after the injection.
• C. At any time, because timing of meals with lispro injections is unnecessary.
• D. 2 hours before the injection.

Correct answer: A

Rationale: The correct answer is to eat within 10 to 15 minutes after the injection. Insulin lispro, also known as Humalog, is a rapid-acting insulin that starts working very quickly. Eating shortly after the injection helps match the food intake with the insulin action, reducing the risk of hypoglycemia. Choice B is incorrect because waiting 1 hour after the injection may lead to a mismatch between insulin activity and food intake. Choice C is incorrect as timing meals with lispro injections is essential to optimize glycemic control. Choice D is incorrect as eating 2 hours before the injection is not in alignment with the rapid action of insulin lispro and may lead to fluctuations in blood sugar levels.

2. A client reports for a scheduled electroencephalogram (EEG). Which statement by the client indicates a need for additional preparation for the test?

• A. I didn’t shampoo my hair.
• B. I ate breakfast this morning.
• C. I didn’t take my anticonvulsant today.
• D. It was hard not to drink coffee this morning, but I knew that I couldn’t, so I didn’t.

Correct answer: A

Rationale: The correct answer is A. For an EEG, it is essential that the client's hair is clean, without any products like hairspray or gel, to ensure good electrode contact with the scalp. Choice B is not a concern as having breakfast is allowed before the test. Choice C, not taking an anticonvulsant, might be required for certain types of EEGs to capture accurate brain activity. Choice D, not drinking coffee, is not a specific requirement for an EEG preparation.

3. What is the priority assessment for a patient receiving intravenous morphine?

• A. Assessing the patient's blood pressure.
• B. Monitoring the patient's respiratory rate.
• C. Checking the patient's pain level.
• D. Monitoring the patient's oxygen saturation.

Correct answer: B

Rationale: The correct answer is monitoring the patient's respiratory rate. When a patient receives intravenous morphine, the priority assessment is to monitor the respiratory rate due to the risk of respiratory depression associated with morphine. This assessment helps in detecting and managing any potential respiratory complications promptly. Assessing blood pressure, checking pain level, and monitoring oxygen saturation are important aspects of patient care but are not the priority when considering the specific risk of respiratory depression with intravenous morphine.

4. A client who underwent surgery and experienced significant blood loss is being cared for by a nurse. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.)

• A. Urine output of 100 mL in 4 hours
• B. Large amount of sediment in the urine
• C. A & B
• D. Amber, odorless urine

Correct answer: C

Rationale: The nurse must monitor for signs of acute kidney injury in a postoperative client who had major blood loss. Low urine output, presence of sediment in the urine, and low blood pressure should raise concerns and be reported to the healthcare provider promptly. Postoperatively, assessing urine characteristics is crucial. Sediment, hematuria, and urine output less than 0.5 mL/kg/hour for 3 to 4 hours should be reported. While a urine output of 100 mL in 4 hours is low, it should be compared to the recommended 0.5 mL/kg/hour over a longer period. Perfusion to the kidneys is a priority, hence the importance of addressing low blood pressure. Amber, odorless urine is considered normal and does not indicate an immediate concern for acute kidney injury, unlike low urine output and presence of sediment.

5. A client without a history of respiratory disease has a pulse oximeter in place after surgery. The nurse monitors the pulse oximeter readings to ensure that oxygen saturation remains above:

• A. 85%
• B. 89%
• C. 95%
• D. 100%

Correct answer: C

Rationale: Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2). In the absence of underlying respiratory disease, the expected oxygen saturation level is at least 95%. Oxygen saturation levels below 95% may indicate hypoxemia, which can compromise tissue perfusion and oxygen delivery to vital organs. Therefore, maintaining oxygen saturation above 95% is crucial to ensure adequate oxygenation post-surgery. Choices A, B, and D are incorrect as they represent oxygen saturation levels that are below the expected value for a client without a history of respiratory disease, which should be at least 95%.

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