Nursing Elites

1. A client with diabetes mellitus is admitted with hyperglycemia. What is the priority nursing action?

• A. Administer insulin as prescribed
• B. Encourage fluid intake
• C. Monitor blood glucose levels frequently
• D. Assess for signs of hypoglycemia

Correct answer: A

Rationale: Administering insulin is the priority nursing action for a client admitted with hyperglycemia due to diabetes mellitus. Insulin helps lower blood glucose levels and prevent further complications associated with hyperglycemia. Encouraging fluid intake is important but not the priority as insulin administration takes precedence to address the immediate hyperglycemic state. Monitoring blood glucose levels frequently is essential but comes after administering insulin to ensure the treatment's effectiveness. Assessing for signs of hypoglycemia is incorrect as the client is admitted with hyperglycemia, which requires raising blood glucose levels, not lowering them further.

2. The healthcare provider plans to assess a newborn and check the infant's Moro reflex. What is the healthcare provider evaluating?

• A. Neurological integrity
• B. Renal functioning
• C. Thermoregulation
• D. Respiratory adequacy

Correct answer: A

Rationale: The Moro reflex is an instinctive response observed in newborns, indicating their neurological integrity. This reflex is evaluated by eliciting a startle response in the infant, involving the sudden extension and abduction of the limbs, followed by their retraction. This assessment helps in determining the proper functioning of the infant's nervous system and brain. Choices B, C, and D are incorrect as they do not relate to the evaluation of the Moro reflex. Renal functioning pertains to kidney function, thermoregulation refers to temperature control, and respiratory adequacy involves assessing breathing and oxygenation levels, none of which are evaluated through the Moro reflex.

3. A client is receiving dexamethasone (Decadron). What symptoms should the nurse recognize as Cushingoid side effects?

• A. Moon face, slow wound healing, muscle wasting, sodium and water retention
• B. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor
• C. Bradycardia, weight gain, cold intolerance, myxedema facies and periorbital edema
• D. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, hypotension

Correct answer: A

Rationale: Cushingoid side effects are characteristic of excess corticosteroid use, such as dexamethasone. These include moon face (rounding of the face), slow wound healing, muscle wasting, and sodium and water retention. Options B, C, and D describe symptoms that are not typically associated with Cushingoid side effects. Tachycardia, hypertension, weight loss, heat intolerance, nervousness, restlessness, tremor (Option B) are not typical of Cushingoid effects, while bradycardia, weight gain, cold intolerance, myxedema facies, and periorbital edema (Option C) are more indicative of hypothyroidism. Hyperpigmentation, hyponatremia, hyperkalemia, dehydration, and hypotension (Option D) are not classical features of Cushingoid side effects.

4. The nurse is caring for a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow down the rate of the transfusion
• B. Administer an antipyretic
• C. Stop the transfusion immediately
• D. Notify the healthcare provider

Correct answer: C

Rationale: Chills and back pain are signs of a possible transfusion reaction, which can indicate severe complications like a hemolytic reaction or sepsis. The priority action for the nurse is to stop the transfusion immediately to prevent further harm to the client. Slowing the rate of the transfusion or administering an antipyretic will not address the underlying cause of the reaction and could potentially worsen the client's condition. Notifying the healthcare provider should be done after ensuring the client's immediate safety by stopping the transfusion.

5. A client with a history of chronic heart failure is admitted with symptoms of dyspnea and fatigue. What initial intervention should the nurse prepare to implement?

• A. Administration of IV diuretics
• B. Oxygen therapy
• C. Bed rest
• D. Dietary consultation

Correct answer: B

Rationale: The correct initial intervention for a client with chronic heart failure presenting with dyspnea and fatigue is oxygen therapy. Oxygen therapy can help relieve dyspnea and improve oxygen saturation levels, which are crucial in managing heart failure exacerbations. Administering IV diuretics may be necessary later to address fluid overload, but oxygen therapy takes precedence in addressing the immediate respiratory distress. Bed rest and dietary consultation are important aspects of care for heart failure patients, but in this scenario, oxygen therapy is the priority to improve the client's respiratory status.

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