Nursing Elites

1. A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following goals should the nurse include in the teaching?

• A. HbA1c level greater than 8%.
• B. Blood glucose level greater than 200 mg/dL at bedtime.
• C. Blood glucose level less than 60 mg/dL before breakfast.
• D. HbA1c level less than 7%.

Correct answer: D

Rationale: The correct answer is D. An HbA1c level less than 7% indicates good long-term glucose control for clients with diabetes. This goal reflects optimal glycemic control and reduces the risk of long-term complications. Choices A, B, and C are incorrect because they do not represent appropriate goals for managing type 1 diabetes in an adolescent. An HbA1c level greater than 8% (choice A) signifies poor glucose control, while a blood glucose level greater than 200 mg/dL at bedtime (choice B) and a blood glucose level less than 60 mg/dL before breakfast (choice C) are not within the target ranges for safe and effective diabetes management.

2. A client with an NG tube is experiencing nausea and a decrease in gastric secretions. What should the nurse do first?

• A. Position the client on their left side
• B. Irrigate the NG tube with sterile water
• C. Replace the NG tube with a new one
• D. Increase the suction setting to relieve the blockage

Correct answer: B

Rationale: The correct first action for a client with an NG tube experiencing nausea and decreased gastric secretions is to irrigate the NG tube with sterile water. This can help clear any blockages in the tube, which may be causing the symptoms. Positioning the client on their left side may be helpful for enteral feedings but is not the priority in this situation. Replacing the NG tube should not be the initial step unless irrigation fails to resolve the issue. Increasing the suction setting without attempting to clear the blockage can be harmful to the client.

3. A nurse is caring for a client post-abdominal surgery who has an NG tube. The client reports nausea and a decrease in gastric output. What should the nurse do first?

• A. Turn the client onto their left side
• B. Irrigate the NG tube with sterile water
• C. Increase the suction pressure to relieve the blockage
• D. Remove the NG tube and replace it with a new one

Correct answer: B

Rationale: The correct answer is to irrigate the NG tube with sterile water first. This action helps to relieve blockages that may be causing the decrease in gastric output and nausea. Turning the client onto their left side may not directly address the issue with the NG tube. Increasing the suction pressure can further exacerbate the problem and should not be done without assessing the situation first. Removing the NG tube and replacing it with a new one is a more invasive step that should be considered only if other measures are unsuccessful.

4. A client undergoing radiation therapy is being taught about skin care by a nurse. Which of the following statements by the client indicates an understanding of the teaching?

• A. I will use a heating pad to soothe the skin
• B. I will avoid using perfumed lotions on the treated area
• C. I will apply cold compresses to the area
• D. I will scrub the area daily with soap and water

Correct answer: B

Rationale: The correct answer is B because avoiding perfumed lotions is important to prevent skin irritation after radiation therapy. Using a heating pad (A) can further damage the skin, applying cold compresses (C) may not be recommended, and scrubbing the area daily with soap and water (D) can be too harsh on the skin, leading to further irritation and damage.

5. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take to prevent atelectasis?

• A. Encourage deep breathing exercises
• B. Encourage the client to cough every 2 hours
• C. Administer an incentive spirometer
• D. Assist the client to ambulate in the hallway

Correct answer: C

Rationale: The correct answer is C: Administer an incentive spirometer. Using an incentive spirometer helps prevent atelectasis by encouraging lung expansion after surgery. Encouraging deep breathing exercises (choice A) is beneficial but may not be as effective as an incentive spirometer. Encouraging the client to cough (choice B) helps with airway clearance but does not directly prevent atelectasis. Assisting the client to ambulate (choice D) is important for preventing complications such as deep vein thrombosis, but it is not the most effective intervention for preventing atelectasis.

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