Nursing Elites

1. A nurse is preparing to teach a client about the management of hypoglycemia. Which sign should the nurse instruct the client to monitor for?

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

Correct answer: A

Rationale: The correct answer is A: Diaphoresis. Diaphoresis, which refers to excessive sweating, is a classic symptom of hypoglycemia. Instructing the client to monitor for diaphoresis is crucial as it can help them recognize and address hypoglycemic events promptly. Polyuria (excessive urination), abdominal pain, and thirst are not typical signs of hypoglycemia. Polyuria is more commonly associated with conditions like diabetes mellitus, while abdominal pain and thirst are not specific indicators of low blood sugar levels.

2. A nurse working in a mental health facility observes a client who has bipolar disorder walk over to a table occupied by other clients and knock their game off the table. Which of the following is an appropriate response by the nurse?

• A. Apologize to the others for your behavior.
• B. I am disappointed that you continue to act out when you are angry.
• C. Come outside with me for a walk.
• D. If you don't calm down, you will have to go into seclusion.

Correct answer: C

Rationale: Offering to go for a walk with the client helps redirect their energy in a non-confrontational way, avoiding escalation of aggressive behavior while promoting de-escalation.

3. A nurse is caring for a client with a prescription for ferrous sulfate. What instruction should the nurse provide?

• A. Avoid strawberries and citrus fruits
• B. Take with fluids other than coffee or tea
• C. Take on a full stomach
• D. Double the dose if you miss a dose

Correct answer: B

Rationale: The correct instruction for a client prescribed ferrous sulfate is to take it with fluids other than coffee or tea. Coffee and tea can hinder iron absorption, so it's important to take the medication with other types of fluids. Choice A is incorrect because strawberries and citrus fruits are sources of vitamin C, which actually enhance iron absorption. Choice C is incorrect because ferrous sulfate is usually recommended to be taken on an empty stomach for better absorption. Choice D is incorrect as doubling the dose of ferrous sulfate can lead to an overdose and severe side effects.

4. A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is a:

• A. Presumptive sign of pregnancy
• B. Probable sign of pregnancy
• C. Positive sign of pregnancy
• D. Possible sign of pregnancy

Correct answer: A

Rationale: The correct answer is A: Presumptive sign of pregnancy. Quickening, or the sensation of fetal movement, is considered a presumptive sign of pregnancy. It is not definitive because other conditions, such as gas or intestinal movement, can mimic the feeling of fetal movement. Choice B, Probable sign of pregnancy, refers to signs that make the nurse reasonably certain that a woman is pregnant, such as a positive pregnancy test. Choice C, Positive sign of pregnancy, includes signs like hearing fetal heart tones or visualizing the fetus on ultrasound, which definitively confirm pregnancy. Choice D, Possible sign of pregnancy, is a vague term and does not specifically relate to any pregnancy sign.

5. A client is being educated by a nurse on how to use a PCA pump postoperatively. Which statement by the client indicates understanding?

• A. I should wait until the pain is severe before using the PCA pump.
• B. My family can press the button for me while I’m asleep.
• C. I will press the button when I start to feel pain.
• D. I will only press the button once per hour.

Correct answer: C

Rationale: The correct answer is C. This statement indicates understanding because the client recognizes that they should use the PCA pump when they start to feel pain. Waiting for the pain to become severe is not recommended as it may lead to inadequate pain control. Option B is incorrect because only the client should control the PCA pump to ensure safety and appropriate dosing. Option D is also incorrect as there is no set limit on how often the button can be pressed, as it should be used as needed when pain is felt.

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