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. A nurse is teaching a client who has peripheral arterial disease (PAD) about exercise recommendations. Which of the following instructions should the nurse include?

• A. Exercise to the point of pain
• B. Stop exercising if pain occurs
• C. Exercise only once per week
• D. Avoid walking to prevent pain

Correct answer: B

Rationale: The correct instruction the nurse should include is to 'Stop exercising if pain occurs.' In peripheral arterial disease (PAD), it is crucial to avoid exercising to the point of pain as this may worsen the condition and lead to complications. Exercising to the point of pain can result in inadequate blood flow to the extremities, causing further damage. By stopping exercise if pain occurs, the client can prevent exacerbating their condition. Choices A, C, and D are incorrect because exercising to the point of pain, limiting exercise to once per week, and avoiding walking altogether are not recommended strategies for managing PAD and could potentially harm the client.

3. What are the key components of a focused respiratory assessment?

• A. Inspection, Palpation, Percussion, Auscultation
• B. Observation, Percussion, Auscultation, Palpation
• C. Auscultation, Palpation, Observation, Percussion
• D. Palpation, Inspection, Auscultation, Percussion

Correct answer: A

Rationale: The correct answer is A: Inspection, Palpation, Percussion, Auscultation. A focused respiratory assessment involves inspecting the chest for any abnormalities, palpating to assess tenderness and chest expansion, percussion to evaluate underlying structures, and auscultation to listen to lung sounds. Choice B is incorrect because observation is generally part of inspection, not a separate component. Choice C is incorrect as auscultation should come before percussion in a respiratory assessment. Choice D is incorrect because inspection should precede palpation in a structured assessment.

4. A client has a prescription for ranitidine 150 mg PO BID. Available is ranitidine syrup 15 mg/mL. How many mL should the nurse administer each day?

• A. 20 mL
• B. 15 mL
• C. 25 mL
• D. 10 mL

Correct answer: A

Rationale: To administer a total of 300 mg daily (150 mg PO BID), the nurse should give 20 mL of the syrup. This is calculated by dividing the total daily dose (300 mg) by the concentration of the syrup (15 mg/mL), which equals 20 mL. Choice B (15 mL), C (25 mL), and D (10 mL) are incorrect because they do not accurately calculate the required volume of syrup needed to deliver the prescribed dose.

5. How should a healthcare provider assess a patient for fluid overload?

• A. Monitor weight and assess for shortness of breath
• B. Auscultate lung sounds and monitor blood pressure
• C. Assess for edema in the extremities
• D. Assess for jugular venous distension

Correct answer: A

Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.

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