Nursing Elites

1. A nurse is teaching a client who has type 1 DM about hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

• A. Exercise reduces the risk for hypoglycemia.
• B. I can skip my insulin when I don't eat.
• C. I can drink 4 oz of soda if my blood sugar is low.
• D. Diabetic pills don't cause hypoglycemia; only insulin does.

Correct answer: C

Rationale: The client can correct any development of hypoglycemia with a quick intake of glucose. The client should have 15 g carbohydrates on hand to treat hypoglycemic episodes, like 4 oz of regular soda.

2. A nurse is assessing a client who has meningitis. The nurse should identify which of the following findings as a positive Kernig's sign?

• A. After stroking the lateral area of the foot, the client's toes contract and draw together
• B. After hip flexion, the client is unable to extend their leg completely without pain
• C. The client's voluntary movement is not coordinated
• D. The client reports pain and stiffness when flexing their neck

Correct answer: B

Rationale: A positive Kernig's sign is identified when a client is unable to extend their leg completely without pain after hip flexion. This finding suggests meningeal irritation. Choices A, C, and D do not describe Kernig's sign. Choice A describes a normal plantar reflex, Choice C refers to coordination deficits, and Choice D indicates neck pain and stiffness, which are not related to Kernig's sign.

3. What are the early signs of compartment syndrome?

• A. Unrelieved pain, pallor, and pulselessness
• B. Localized redness and swelling
• C. Fever and infection
• D. Loss of sensation in the affected area

Correct answer: A

Rationale: The correct answer is A: Unrelieved pain, pallor, and pulselessness. These signs are typical early indicators of compartment syndrome, suggesting compromised circulation. Choice B, localized redness and swelling, can be seen in conditions like cellulitis but are not specific to compartment syndrome. Choice C, fever and infection, are not characteristic early signs of compartment syndrome. Choice D, loss of sensation in the affected area, is more indicative of nerve damage rather than being one of the early signs of compartment syndrome.

4. What intervention should be done if continuous bubbling is seen in the chest tube water seal chamber?

• A. Tighten the connections of the chest tube system
• B. Replace the chest tube system
• C. Clamp the chest tube
• D. Continue monitoring the chest tube

Correct answer: A

Rationale: When continuous bubbling is observed in the chest tube water seal chamber, the appropriate intervention is to tighten the connections of the chest tube system. This step helps address an air leak in the system, which could compromise its effectiveness. Choice B (Replace the chest tube system) is not the initial step and may be unnecessary if the issue can be resolved by tightening connections. Choice C (Clamp the chest tube) is incorrect as clamping the chest tube could lead to a dangerous increase in pressure within the system. Choice D (Continue monitoring the chest tube) is also not the best immediate action to take when continuous bubbling is present, as prompt intervention is needed to prevent complications.

5. During an escharotomy on a patient with a burn injury, what is the purpose of this procedure?

• A. To release pressure and improve circulation in the affected area
• B. To remove dead tissue from the burn area
• C. To improve breathing by reducing skin tightness
• D. To prevent infection in the burned area

Correct answer: A

Rationale: Corrected Question: During an escharotomy on a patient with a burn injury, the purpose of this procedure is to release pressure and improve circulation in the affected area. This intervention is crucial in severe burns where the formation of eschar (dead tissue) can lead to increased pressure, compromising circulation and potentially causing further tissue damage. Choices B, C, and D are incorrect because escharotomy specifically aims to address pressure and circulation issues in severe burn injuries, rather than removing dead tissue, improving breathing, or preventing infection.

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