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 is preparing to administer lactated Ringer's (LR) 1,000 mL IV to infuse over 8 hr. The drop factor of the manual IV tubing is 10 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min?

• A. 19 gtt/min
• B. 20 gtt/min
• C. 21 gtt/min
• D. 22 gtt/min

Correct answer: C

Rationale: Calculation: 1000 mL / 480 minutes × 10 gtt/mL = 20.83, rounded to 21 gtt/min. This ensures proper IV fluid administration over the prescribed time. Choice C is the correct answer as it reflects the accurate calculation based on the given parameters. Choice A is incorrect because it does not accurately calculate the infusion rate. Choice B is incorrect as it does not consider the precise calculation required. Choice D is incorrect as it deviates from the correct calculation.

3. A nurse is caring for a client receiving oxytocin IV for labor augmentation. The client’s contractions are occurring every 45 seconds and lasting 90 seconds. What action should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: In this scenario, the client is experiencing uterine hyperstimulation with contractions every 45 seconds lasting 90 seconds. This frequency and duration of contractions can lead to fetal distress. The appropriate nursing action is to discontinue the oxytocin infusion immediately to prevent complications. Increasing or maintaining the oxytocin infusion would exacerbate the situation, while decreasing it may not be sufficient to address the issue effectively.

4. While caring for a client receiving nitroglycerin for chest pain, which of the following side effects should the nurse monitor for?

• A. Hypotension
• B. Tachycardia
• C. Bradycardia
• D. Hyperglycemia

Correct answer: A

Rationale: Corrected Rationale: Nitroglycerin is known to cause hypotension due to its vasodilating effect, which can lead to low blood pressure. Therefore, the nurse should closely monitor the client for signs of hypotension such as dizziness, light-headedness, or weakness. Tachycardia (increased heart rate), bradycardia (decreased heart rate), and hyperglycemia (high blood sugar) are not typically associated with nitroglycerin use and are less likely to be side effects that the nurse needs to monitor for in this scenario.

5. A client who signed an informed consent form for surgery but has since expressed doubts about the need for surgery should discuss concerns with the surgeon to obtain informed answers. Which statement should the nurse make?

• A. It's normal to feel unsure; the surgery will be beneficial
• B. You can cancel surgery any time without any consequences
• C. I'll inform the surgeon to answer your questions before surgery
• D. We can reschedule surgery for another day

Correct answer: C

Rationale: The correct answer is C because the nurse should facilitate communication between the client and the surgeon to address any doubts and provide necessary information. Choice A may invalidate the client's concerns and might not address the root of the issue. Choice B oversimplifies the situation and might not consider the potential consequences of canceling surgery. Choice D, while offering an alternative, does not address the client's doubts about the surgery.

Similar Questions