Nursing Elites

1. A nurse administers insulin for a misread glucose level. What should the nurse monitor for?

• A. Monitor for hypoglycemia
• B. Monitor for hyperglycemia
• C. Monitor for hyperkalemia
• D. Document the incident

Correct answer: A

Rationale: When a nurse administers insulin for a misread glucose level, they should monitor for hypoglycemia. Insulin lowers blood sugar levels, so the patient may experience hypoglycemia if given insulin unnecessarily. Monitoring for hypoglycemia involves observing for symptoms such as shakiness, sweating, dizziness, confusion, and palpitations. Choices B and C are incorrect because administering insulin for a misread glucose level would lower blood sugar levels, resulting in hypoglycemia, not hyperglycemia or hyperkalemia. Choice D is not the immediate priority; the focus should be on patient safety and monitoring for potential adverse effects of the unnecessary insulin.

2. A nurse is teaching a group of assistive personnel (AP) about caring for clients who have Alzheimer's disease. Which of the following information should the nurse include in the teaching?

• A. Explain procedures clearly and concisely to the client before initiating care
• B. Encourage a client's engagement in appropriate activities to minimize emotional outbursts
• C. Speak calmly and at a moderate volume to a client who is unable to form words or sentences
• D. Provide supervision to prevent a client from becoming injured or lost

Correct answer: D

Rationale: The correct answer is D because clients with Alzheimer's disease are at risk of wandering and becoming lost. Providing supervision helps prevent them from getting injured or lost. Choice A is incorrect because extensive details may overwhelm clients with Alzheimer's. Choice B is incorrect because limiting activities can lead to boredom and behavioral issues. Choice C is incorrect because speaking calmly and at a moderate volume helps to reduce agitation and confusion in clients with Alzheimer's.

3. What lab value should be prioritized in a patient with HIV?

• A. CD4 T-cell count below 180 cells/mm3
• B. Hemoglobin levels
• C. Serum albumin levels
• D. White blood cell count

Correct answer: A

Rationale: The correct answer is A: CD4 T-cell count below 180 cells/mm3. In a patient with HIV, monitoring the CD4 T-cell count is crucial as it reflects the status of the immune system. A CD4 T-cell count below 200 cells/mm3 indicates severe immunocompromise and risk of opportunistic infections. Hemoglobin levels (choice B) are important for assessing anemia but do not directly reflect the immune status in HIV patients. Serum albumin levels (choice C) are indicators of nutritional status and inflammation, not specific to HIV disease progression. White blood cell count (choice D) may fluctuate due to various conditions and is not as specific as the CD4 T-cell count in assessing HIV progression.

4. What are the expected signs of compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Fever, swelling, and redness
• C. Muscle cramps and weakness
• D. Redness and itching

Correct answer: A

Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. Compartment syndrome is characterized by increased pressure within a muscle compartment, leading to inadequate blood supply. This results in severe pain that is unrelieved by rest or medication, pallor due to compromised blood flow, and pulselessness as a late sign of severe ischemia. Choices B, C, and D are incorrect. Fever, swelling, and redness are not typical signs of compartment syndrome. Muscle cramps and weakness may occur due to other conditions, but they are not primary indicators of compartment syndrome. Redness and itching are also not commonly associated with compartment syndrome.

5. What should the nurse do when a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the enema solution container
• B. Stop the procedure and remove the tubing
• C. Continue the enema at a slower rate
• D. Increase the flow of the enema solution

Correct answer: A

Rationale: When a patient experiences abdominal cramping during enema administration, the nurse should lower the height of the enema solution container. Lowering the height helps relieve cramping by slowing down the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is incorrect as it does not directly address the cramping issue. Choice C, continuing the enema at a slower rate, could potentially worsen the cramping by prolonging the discomfort. Choice D, increasing the flow of the enema solution, is also incorrect as it may intensify the cramping and cause more discomfort to the patient.

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