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 postpartum client with AB negative blood whose newborn is B positive requires what intervention?

• A. Administer Rh immune globulin within 72 hours of delivery
• B. Administer Rh immune globulin at the 6-week postpartum visit
• C. No Rh immune globulin is needed since this is the second pregnancy
• D. Both mother and baby need Rh immune globulin

Correct answer: A

Rationale: The correct intervention is to administer Rh immune globulin within 72 hours of delivery. This is essential to prevent the mother from forming antibodies against Rh-positive blood, which could cause complications in future pregnancies. Choice B is incorrect as the administration should be immediate postpartum. Choice C is incorrect as Rh immune globulin is needed for each Rh-incompatible pregnancy. Choice D is incorrect as only the mother, who is Rh-negative, needs Rh immune globulin.

3. A nurse is planning care for a client who has a sealed radiation implant and is to remain in the hospital for one week. Which of the following should the nurse include in the plan of care?

• A. Remove dirty linens from the room after double-bagging them
• B. Wear a dosimeter film badge while in the client’s room
• C. Limit each visitor to one hour per day
• D. Ensure family members remain at least 3 feet from the client

Correct answer: B

Rationale: The correct answer is to wear a dosimeter film badge while in the client's room. Wearing a dosimeter helps monitor the cumulative radiation exposure of healthcare workers, ensuring their safety during care. Removing dirty linens, limiting visitor time, and maintaining a distance from the client are not directly related to radiation safety measures and are not necessary in this scenario.

4. A nurse is assessing a client who is at risk for falls. Which of the following findings should the nurse recognize as increasing the client's risk of falling?

• A. Normal gait
• B. Recent history of dizziness
• C. 20/20 vision
• D. Takes a multivitamin daily

Correct answer: B

Rationale: The correct answer is B: Recent history of dizziness. A recent history of dizziness significantly increases the risk of falling, as dizziness can impair balance and coordination. Having a normal gait (choice A) and 20/20 vision (choice C) are not factors that directly increase the risk of falling. Taking a multivitamin daily (choice D) does not inherently contribute to an increased risk of falling unless it causes dizziness as a side effect, which is not specified in the question.

5. A nurse in a mental health facility receives a change-of-shift report on four clients. Which of the following clients should the nurse assess first?

• A. Client placed in restraints for aggressive behavior
• B. A new client with a history of a 4.5 kg weight loss in the past two months
• C. Client who received a PRN dose of haloperidol 2 hours ago for increased anxiety
• D. Client who will be receiving his first ECT treatment today

Correct answer: A

Rationale: A client in restraints due to aggressive behavior needs immediate assessment to ensure safety and well-being. The nurse should assess this client first to address any potential risks, such as circulation issues, skin integrity problems, and ongoing agitation. Choices B, C, and D do not present immediate safety concerns that require urgent assessment compared to a client restrained for aggressive behavior.

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