Nursing Elites

1. A client who is immobile needs interventions to prevent contractures. Which of the following interventions is appropriate?

• A. Aligning a trochanter wedge between the client's legs.
• B. Placing a towel roll under the client's neck.
• C. Applying an orthotic to the client's foot.
• D. Positioning a pillow under the client's knees.

Correct answer: C

Rationale: Applying an orthotic to the client's foot is the appropriate intervention to prevent contractures in an immobile client. An orthotic helps maintain proper alignment and prevents the development of contractures by keeping the foot in the correct position. Choices A, B, and D are incorrect because a trochanter wedge, towel roll under the neck, and pillow under the knees are not specific interventions for preventing contractures in an immobile client.

2. Which of the following is the best strategy for managing dehydration in a client?

• A. Encourage the client to drink more water
• B. Monitor fluid and electrolyte levels frequently
• C. Administer oral rehydration solutions
• D. Increase the IV fluid rate

Correct answer: B

Rationale: The best strategy for managing dehydration in a client is to monitor fluid and electrolyte levels frequently. This allows healthcare providers to assess the client's hydration status accurately and make informed decisions regarding treatment. Encouraging the client to drink more water (Choice A) may not be sufficient if the dehydration is severe and requires specific interventions. Administering oral rehydration solutions (Choice C) can be beneficial but should be guided by monitoring the client's condition. Increasing the IV fluid rate (Choice D) may be necessary in certain cases, but it is not always the initial or best approach, as monitoring is crucial to avoid fluid and electrolyte imbalances.

3. 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.

4. How should a healthcare provider manage a patient with Type 1 diabetes?

• A. Administer insulin and monitor blood glucose levels
• B. Provide a low-carbohydrate diet and oral hypoglycemics
• C. Administer oral hypoglycemics and provide dietary education
• D. Provide a high-protein diet and insulin injections

Correct answer: A

Rationale: Type 1 diabetes is managed with insulin administration and regular blood glucose monitoring. Choice A is correct because administering insulin is essential in Type 1 diabetes management to help regulate blood glucose levels. Choices B, C, and D are incorrect because Type 1 diabetes requires insulin therapy as the primary treatment, not oral hypoglycemics or dietary modifications like low-carbohydrate or high-protein diets. Monitoring blood glucose levels is crucial in adjusting insulin doses and ensuring optimal management of the condition.

5. A nurse is caring for a client who has diabetes mellitus and is receiving insulin. Which of the following findings should the nurse report to the provider?

• A. A fasting blood glucose of 90 mg/dL
• B. A blood glucose level of 200 mg/dL
• C. A hemoglobin A1c of 6%
• D. A fasting blood glucose of 100 mg/dL

Correct answer: B

Rationale: The correct answer is B. A blood glucose level of 200 mg/dL indicates hyperglycemia, which may necessitate insulin adjustment to better control the client's blood sugar levels. A fasting blood glucose of 90 mg/dL (choice A) is within the normal range, a hemoglobin A1c of 6% (choice C) is indicative of good long-term blood sugar control, and a fasting blood glucose of 100 mg/dL (choice D) is also within the normal range. Therefore, these findings do not require immediate reporting to the provider.

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