Nursing Elites

1. A client with diabetes mellitus has a blood glucose level of 350 mg/dL. Which of these actions should the nurse take first?

• A. Administer insulin as ordered
• B. Encourage the client to drink fluids
• C. Notify the healthcare provider
• D. Recheck the blood glucose level in 30 minutes

Correct answer: A

Rationale: Administering insulin as ordered is the priority action when a client with diabetes mellitus has a blood glucose level of 350 mg/dL. Insulin helps to lower the high blood glucose level and prevent complications such as diabetic ketoacidosis. Encouraging the client to drink fluids may be beneficial but does not address the immediate need to lower the blood glucose level. Notifying the healthcare provider and rechecking the blood glucose level can be important steps but should come after administering insulin to address the high glucose level promptly.

2. A client is lactose intolerant, and a nurse is reinforcing teaching. Which of the following statements should the nurse include?

• A. You should increase the fiber in your diet.
• B. You should increase the calories in your diet.
• C. You should decrease the dairy products in your diet.
• D. You should decrease the amount of vitamin D in your diet.

Correct answer: C

Rationale: The correct statement for a client who is lactose intolerant is to decrease dairy products since lactose intolerant individuals should avoid dairy to prevent symptoms like bloating, diarrhea, and gas. Increasing fiber (Choice A) or calories (Choice B) is not directly related to lactose intolerance. Decreasing vitamin D (Choice D) is not necessary as lactose intolerance is about the sugar in dairy, not vitamin D.

3. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?

• A. FHT 168 beats/min
• B. Temperature 100 degrees Fahrenheit
• C. Cervical dilation of 4 cm
• D. BP 138/88

Correct answer: A

Rationale: The correct answer is A. Fetal heart rate elevation can indicate distress, making it an early sign of labor complications. Choices B, C, and D are not the best answers in this scenario. Choice B, an elevated temperature, could indicate infection but is not a direct sign of labor complications. Choice C, cervical dilation of 4 cm, is a normal part of labor progression for a primigravida. Choice D, a blood pressure of 138/88, falls within normal limits and is not an early indication of labor complications.

4. What should a client with diarrhea avoid consuming?

• A. Orange juice
• B. Tuna
• C. Eggs
• D. Macaroni

Correct answer: A

Rationale: A client with diarrhea should avoid consuming orange juice. Orange juice is high in sugar content, which can worsen diarrhea symptoms by drawing water into the intestines, potentially leading to further dehydration and discomfort. Tuna, eggs, and macaroni are generally well-tolerated and do not exacerbate diarrhea symptoms, making them more suitable food choices for individuals experiencing diarrhea.

5. A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to

• A. have the client identify coping methods
• B. get the description of the location and intensity of the pain
• C. accept the client's report of pain
• D. determine the client's status of pain

Correct answer: B

Rationale: The correct answer is B: 'get the description of the location and intensity of the pain.' When a client complains of pain, the initial step in pain assessment is to gather information about the location and intensity of the pain. This helps the nurse understand the nature of the pain and lays the groundwork for further assessment and management. Choice A is incorrect because identifying coping methods comes later in the assessment process. Choice C is incorrect as accepting the client's report of pain is important, but not the first step. Choice D is incorrect as determining the client's pain status also comes after gathering information about the pain.

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