Nursing Elites

1. A nurse is planning an education session for a client who has type 1 diabetes mellitus. Which of the following should the nurse plan to include when teaching the client to monitor for hypoglycemia?

• A. Diaphoresis
• B. Polyuria
• C. Abdominal pain
• D. Thirst

Correct answer: A

Rationale: The correct answer is A: Diaphoresis. Diaphoresis (sweating) is a classic symptom of hypoglycemia, along with shakiness, confusion, and irritability. These signs help indicate low blood sugar levels. Choices B, C, and D are incorrect. Polyuria (excessive urination), abdominal pain, and thirst are not typical symptoms associated with hypoglycemia. It is crucial for clients with type 1 diabetes mellitus to recognize the early signs of hypoglycemia to take prompt corrective action.

2. A client is being taught about the use of nitroglycerin. Which of the following should be included?

• A. Take it with food
• B. Place the tablet under the tongue
• C. It can be stored in the refrigerator
• D. It has no side effects

Correct answer: B

Rationale: The correct answer is to place the nitroglycerin tablet under the tongue. Nitroglycerin tablets are meant for sublingual absorption during angina episodes to provide quick relief. Option A is incorrect because nitroglycerin should not be taken with food. Option C is incorrect as nitroglycerin should be stored in a cool, dark place, not in the refrigerator. Option D is incorrect because nitroglycerin can have side effects, including headaches, dizziness, and low blood pressure.

3. A client prescribed allopurinol for gout is being taught by a nurse. Which of the following should be included in the teaching?

• A. Take the medication with meals.
• B. Drink at least 2 liters of water per day.
• C. Avoid foods high in purines.
• D. Increase your dietary intake of calcium.

Correct answer: B

Rationale: The correct answer is B: 'Drink at least 2 liters of water per day.' Clients taking allopurinol should be instructed to drink plenty of water to prevent kidney stones, a potential side effect of the medication. Option A is incorrect because allopurinol is usually taken without regard to meals. Option C is not directly related to the teaching about allopurinol, as it pertains more to dietary management of gout. Option D is also unrelated to allopurinol use for gout.

4. A nurse is reviewing the medication class, benzodiazepines. The nurse would use caution when administering benzodiazepines to which of the clients below?

• A. A client with glaucoma
• B. A client with renal failure
• C. A client with hypertension
• D. A client with insomnia

Correct answer: A

Rationale: Benzodiazepines can increase intraocular pressure, which is why they must be used cautiously in patients with glaucoma. In clients with this condition, benzodiazepines can potentially worsen symptoms and lead to further complications involving the eyes. Therefore, administering benzodiazepines to a client with glaucoma should be done with caution. Choices B, C, and D are not directly contraindicated with benzodiazepines, making them less likely to cause harm compared to administering to a client with glaucoma.

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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