Nursing Elites

1. A nurse is administering insulin to a patient after misreading their glucose as 210 mg/dL instead of 120 mg/dL. What should the nurse monitor for?

• A. Monitor for hypoglycemia
• B. Monitor for hyperkalemia
• C. Administer glucose IV
• D. Document the incident

Correct answer: A

Rationale: The correct answer is to monitor for hypoglycemia. Insulin administration based on a misread glucose level can lead to hypoglycemia due to the unnecessary lowering of blood sugar levels. Monitoring for hypoglycemia involves assessing the patient's blood glucose levels frequently, observing for signs and symptoms such as shakiness, confusion, sweating, and administering glucose if hypoglycemia occurs. Choice B, monitoring for hyperkalemia, is incorrect as insulin administration typically lowers potassium levels. Choice C, administering glucose IV, is not the immediate action needed as the patient could potentially develop hypoglycemia from the excess insulin. Choice D, documenting the incident, is important but not the immediate priority when dealing with a potential hypoglycemic event.

2. What is an escharotomy and when is it performed?

• A. A surgical incision to release pressure in burn injuries
• B. A procedure to remove dead tissue from wounds
• C. An incision to improve circulation in tight skin after burns
• D. A procedure to remove excess fluid from the chest

Correct answer: A

Rationale: An escharotomy is a surgical incision made to release pressure in a part of the body that has a deep burn and excessive swelling. This procedure is crucial in preventing further damage due to restricted blood flow and compromised circulation. Choice B is incorrect because it describes debridement, which is the removal of dead tissue from wounds. Choice C is incorrect as it does not specifically address the purpose of relieving pressure in burn injuries. Choice D is incorrect as it describes a procedure more related to thoracentesis, which is the removal of excess fluid from the chest, typically the pleural space.

3. A patient who received an enema reports abdominal cramping. What should the nurse do?

• A. Increase the flow of the enema solution
• B. Lower the height of the enema solution container
• C. Remove the enema tubing
• D. Stop the procedure

Correct answer: B

Rationale: When a patient who received an enema reports abdominal cramping, the nurse should lower the height of the enema solution container. This adjustment can help reduce the cramping by slowing down the flow of the solution into the colon, allowing the patient to tolerate the procedure better. Increasing the flow of the solution (Choice A) can exacerbate the cramping. Removing the enema tubing (Choice C) or stopping the procedure (Choice D) may not address the issue and could lead to incomplete treatment.

4. What are the dietary recommendations for a patient with pre-dialysis end-stage kidney disease?

• A. Reduce phosphorus intake to 700 mg/day
• B. Limit sodium intake to 1,500 mg/day
• C. Restrict protein intake to 0.55-0.60 g/kg/day
• D. Increase protein intake

Correct answer: A

Rationale: The correct recommendation for a patient with pre-dialysis end-stage kidney disease is to reduce phosphorus intake to 700 mg/day. High phosphorus levels can be harmful to individuals with kidney disease as the kidneys may not be able to filter it effectively. While limiting sodium intake to 1,500 mg/day and restricting protein intake to 0.55-0.60 g/kg/day are important in managing kidney disease, the primary concern for this patient population is to control phosphorus levels. Increasing protein intake is not recommended as it can put additional strain on the kidneys. Therefore, option A is the most appropriate recommendation in this scenario.

5. A nurse is providing teaching to a client who was newly diagnosed with nephrotic syndrome. Which of the following statements should indicate to the nurse that the client understands the teaching?

• A. I can expect swelling in my hands and on my face.
• B. The amount of protein in my blood is high.
• C. I might have some pain and gas in my stomach from this condition.
• D. I will use a soft bristle toothbrush to prevent bleeding gums.

Correct answer: A

Rationale: The correct answer is A. Nephrotic syndrome leads to edema, especially of the face and dependent areas, due to the loss of protein in the urine. Choice B is incorrect because nephrotic syndrome leads to protein loss in the urine, not an increase in blood protein levels. Choice C is incorrect as stomach pain and gas are not typical symptoms of nephrotic syndrome. Choice D is incorrect as using a soft bristle toothbrush is not directly related to the manifestations of nephrotic syndrome.

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