Nursing Elites

1. A client with diabetes mellitus is experiencing hypoglycemia. Which of the following actions should the nurse take?

• A. Administer insulin
• B. Administer glucagon
• C. Administer 4 oz of orange juice
• D. Administer 1 L of water

Correct answer: C

Rationale: Administering 4 oz of orange juice is the appropriate action for a client experiencing hypoglycemia due to diabetes mellitus. Orange juice contains simple sugars that can quickly raise blood glucose levels. Insulin (Choice A) would further lower blood sugar, worsening the condition. Glucagon (Choice B) is used in severe hypoglycemia when the client cannot take anything by mouth. Administering 1 L of water (Choice D) is not indicated in hypoglycemia treatment; the priority is to raise blood sugar levels. Therefore, the correct choice is to administer orange juice to address the low blood sugar in this situation.

2. When caring for a client with a wound infection, what should the nurse prioritize?

• A. Change the dressing daily
• B. Cleanse the wound with an antiseptic solution
• C. Apply a wet-to-dry dressing to the wound
• D. Perform a wound culture before administering antibiotics

Correct answer: D

Rationale: The nurse should prioritize performing a wound culture before administering antibiotics to ensure appropriate treatment. This step helps identify the specific infecting organism and its susceptibility to different antibiotics, guiding effective antibiotic therapy. Changing the dressing daily (Choice A) is important but comes after assessing the infection and initiating appropriate treatment. Cleansing the wound with an antiseptic solution (Choice B) and applying a wet-to-dry dressing (Choice C) are interventions that may be necessary but are secondary to determining the most suitable antibiotic therapy based on the wound culture results.

3. What are the key signs of infection after surgery?

• A. Redness
• B. Swelling
• C. Fever
• D. All of the above

Correct answer: D

Rationale: After surgery, key signs of infection include redness, swelling, and fever. Redness and swelling can indicate inflammation at the surgical site, while fever is a systemic response to infection. Choosing 'All of the above' (Option D) is the correct answer because all three signs are commonly associated with post-surgical infections. Options A, B, and C are incorrect as each of them individually can be a sign of infection, but considering all three together provides a more comprehensive assessment for post-operative infection.

4. What is the priority nursing action for a dehydrated client who needs fluids?

• A. Administer antiemetics to prevent vomiting
• B. Monitor electrolyte levels frequently
• C. Administer oral rehydration solutions
• D. Insert an NG tube for fluid administration

Correct answer: B

Rationale: The correct answer is to monitor electrolyte levels frequently. When a client is dehydrated and needs fluids, it is essential to monitor electrolyte levels to prevent complications such as electrolyte imbalances. Administering antiemetics to prevent vomiting (Choice A) may be necessary but is not the priority when addressing dehydration. Administering oral rehydration solutions (Choice C) can be beneficial, but monitoring electrolyte levels takes precedence to ensure proper hydration. Inserting an NG tube for fluid administration (Choice D) is invasive and not typically the first-line approach for managing dehydration.

5. What should a healthcare professional do when they observe signs of phlebitis in a client receiving IV fluids?

• A. Apply a cold compress
• B. Notify the physician immediately
• C. Apply a warm compress
• D. Administer anti-inflammatory medication

Correct answer: C

Rationale: When signs of phlebitis are observed in a client receiving IV fluids, the appropriate action is to apply a warm compress. This helps to reduce discomfort and swelling at the site of the IV insertion. Applying a cold compress may not be as effective in this case and could potentially worsen the condition. While notifying the physician is important, providing immediate comfort to the client through a warm compress is the initial recommended intervention. Administering anti-inflammatory medication should only be done under the direction of a healthcare provider after assessment and evaluation of the client's condition.

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