Nursing Elites

1. A nurse is caring for a client who has been experiencing repeated tonic-clonic seizures over the course of 30 min. After maintaining the client’s airway and turning the client on their side, which of the following medications should the nurse administer?

• A. Diazepam IV
• B. Lorazepam PO
• C. Diltiazem IV
• D. Clonazepam PO

Correct answer: A

Rationale: In the scenario of a client experiencing prolonged seizures, such as status epilepticus, the priority is to administer a benzodiazepine to stop the seizure activity. Diazepam is the medication of choice for this situation due to its rapid onset of action and effectiveness in terminating seizures quickly. Lorazepam, although another benzodiazepine, is typically given through routes other than oral (PO) administration in emergency situations. Diltiazem is a calcium channel blocker used for cardiac conditions, not for seizure management. Clonazepam is a benzodiazepine, but it is usually not the first choice in the acute management of status epilepticus.

2. A client with diabetes is receiving education on foot care. Which of the following should be included in the teaching?

• A. Inspect feet daily for cuts and sores
• B. Soak feet in warm water daily
• C. Wear closed-toe shoes at all times
• D. Trim toenails straight across

Correct answer: A

Rationale: The correct answer is A: Inspect feet daily for cuts and sores. Clients with diabetes are at an increased risk of foot complications, so it is essential to check for any cuts, sores, or injuries daily to prevent infections and complications. Soaking feet in warm water daily (choice B) is not recommended as it can lead to skin breakdown. Wearing closed-toe shoes at all times (choice C) is not advisable as it can cause excessive pressure and friction. Trimming toenails straight across (choice D) is the correct method to prevent ingrown toenails, not trimming them in a rounded shape.

3. A nurse is teaching a client with gestational diabetes about blood sugar control. Which of the following statements indicates understanding?

• A. I should test my blood sugar before each meal.
• B. I can eat any foods as long as I take my insulin.
• C. I should avoid all carbohydrates in my diet.
• D. I will only need to monitor my blood sugar at bedtime.

Correct answer: A

Rationale: The correct answer is A: 'I should test my blood sugar before each meal.' Monitoring blood sugar before meals is crucial for managing gestational diabetes as it helps in understanding how different foods affect blood sugar levels and adjusting insulin doses accordingly. Choice B is incorrect as food choices should be monitored carefully, not just relying on insulin. Choice C is incorrect because while it is important to manage carbohydrate intake, completely avoiding all carbohydrates is not recommended. Choice D is incorrect as blood sugar monitoring throughout the day is essential, not just at bedtime, to ensure proper control and management of gestational diabetes.

4. A nurse is assessing a client with chronic kidney disease. Which of the following should the nurse monitor for?

• A. Hyperkalemia
• B. Hypercalcemia
• C. Hypoglycemia
• D. Hyponatremia

Correct answer: A

Rationale: The correct answer is A: Hyperkalemia. Clients with chronic kidney disease are at risk for hyperkalemia due to impaired potassium excretion. In chronic kidney disease, the kidneys are unable to effectively excrete potassium, leading to its accumulation in the blood. Hypercalcemia (Choice B) is not typically associated with chronic kidney disease. Hypoglycemia (Choice C) refers to low blood sugar levels and is not directly related to chronic kidney disease. Hyponatremia (Choice D) is a condition characterized by low sodium levels and is not a typical concern in chronic kidney disease.

5. A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine. Which of the following interventions should the nurse include in the plan?

• A. Inspect the pin site every 4 hours
• B. Monitor the client’s skin under the halo vest
• C. Ensure two personnel hold the halo device when repositioning the client
• D. Apply powder frequently to the client’s skin under the vest to decrease itching

Correct answer: B

Rationale: The correct answer is to monitor the client’s skin under the halo vest. This is important to assess for signs of skin issues such as excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. Choice A is incorrect because inspecting the pin site every 4 hours is necessary but not the priority in this case. Choice C is incorrect as it is not essential for two personnel to hold the halo device during repositioning. Choice D is incorrect because applying powder frequently can actually increase the risk of skin issues by clogging pores and causing irritation.

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