Nursing Elites

1. A nurse is assessing a client who has diabetes mellitus and is experiencing hypoglycemia. Which of the following findings should the nurse expect?

• A. Tachycardia
• B. Dry mouth
• C. Diaphoresis
• D. Increased appetite

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common sign of hypoglycemia due to the activation of the sympathetic nervous system. Tachycardia (choice A) is more commonly associated with hyperglycemia. Dry mouth (choice B) is not a typical finding in hypoglycemia but may be seen in hyperglycemia. Increased appetite (choice D) is not a typical sign of hypoglycemia and is more commonly associated with hyperglycemia.

2. A nurse is assessing a client who has a new prescription for enoxaparin. Which of the following findings is a priority for the nurse to report?

• A. Platelet count of 200,000/mm³
• B. Hemoglobin level of 15 g/dL
• C. Respiratory rate of 22/min
• D. Dark, tarry stools

Correct answer: D

Rationale: The correct answer is D. Dark, tarry stools indicate gastrointestinal bleeding, which is a serious side effect of enoxaparin that requires immediate medical attention. Reporting this finding promptly is crucial to prevent further complications. Choices A, B, and C are within normal ranges and are not directly related to the adverse effects of enoxaparin, so they do not take precedence over the urgent concern of gastrointestinal bleeding.

3. A client has a new prescription for hydrochlorothiazide. Which of the following instructions should the nurse include?

• A. Take this medication at bedtime to prevent dizziness.
• B. Increase your intake of potassium-rich foods.
• C. Take this medication with food to prevent gastrointestinal upset.
• D. This medication can increase your blood pressure.

Correct answer: B

Rationale: The correct instruction that the nurse should include for a client prescribed hydrochlorothiazide is to increase their intake of potassium-rich foods. Hydrochlorothiazide is a diuretic that can lead to potassium depletion, so increasing potassium-rich foods helps prevent hypokalemia. Option A is incorrect because hydrochlorothiazide is usually taken in the morning to prevent diuresis at night. Option C is not necessary as hydrochlorothiazide can be taken with or without food. Option D is incorrect because hydrochlorothiazide is used to lower blood pressure, not increase it.

4. A nurse is preparing to administer medications to a client who has a nasogastric (NG) tube. Which of the following actions should the nurse take first?

• A. Check for tube placement.
• B. Flush the NG tube with 0.9% sodium chloride.
• C. Administer the medications as a bolus.
• D. Dissolve the medications in 30 mL of sterile water.

Correct answer: A

Rationale: The correct first action for the nurse to take when preparing to administer medications to a client with a nasogastric (NG) tube is to check for tube placement. This step is crucial to ensure that the NG tube is correctly positioned in the stomach and not in the respiratory tract, reducing the risk of aspiration. Flushing the NG tube with 0.9% sodium chloride, administering the medications as a bolus, or dissolving the medications in sterile water should only be done after confirming the proper placement of the NG tube. Therefore, options B, C, and D are incorrect as they precede the essential step of verifying tube placement.

5. A healthcare professional is reviewing laboratory results for a client who has cirrhosis. Which of the following findings should the professional report to the provider?

• A. Albumin 3.5 g/dL
• B. Bilirubin 1.0 mg/dL
• C. INR 3.0
• D. Ammonia 80 mcg/dL

Correct answer: C

Rationale: An INR of 3.0 is elevated, indicating impaired blood clotting function, which poses a significant risk of bleeding in clients with cirrhosis. This finding should be promptly reported to the provider for further evaluation and management. Choice A (Albumin 3.5 g/dL) is within the normal range and indicates adequate liver synthetic function, so it does not require immediate reporting. Choice B (Bilirubin 1.0 mg/dL) is also within the normal range and typically seen in clients without significant liver dysfunction, so it does not need urgent attention. Choice D (Ammonia 80 mcg/dL) is elevated, but it is not the priority finding in cirrhosis; elevated ammonia levels are associated with hepatic encephalopathy rather than increased bleeding risk.

Similar Questions