Nursing Elites

1. A nurse is teaching a client with diabetes about insulin administration. What is the most important point to emphasize?

• A. Check blood sugar once in the morning
• B. Administer insulin before meals as prescribed
• C. Administer insulin only when feeling unwell
• D. Monitor blood sugar only in the evening

Correct answer: B

Rationale: The most important point to emphasize when teaching a client with diabetes about insulin administration is to administer insulin before meals as prescribed. This is crucial for maintaining proper blood sugar control throughout the day. Choice A is incorrect because blood sugar levels need to be monitored multiple times a day, not just once in the morning. Choice C is incorrect because insulin should be administered according to the prescribed schedule, not only when feeling unwell. Choice D is incorrect because blood sugar monitoring should be done at various times during the day, not just in the evening.

2. What is an important consideration when administering a blood transfusion?

• A. Ensure the blood is compatible with the recipient's blood type
• B. Warm the blood to body temperature before administration
• C. Check the blood for clots before administration
• D. Ensure the recipient eats before the transfusion

Correct answer: A

Rationale: The correct answer is to ensure the blood is compatible with the recipient's blood type. This is crucial to prevent transfusion reactions, which can be life-threatening. Choice B is incorrect because warming blood to body temperature is not a standard practice and may lead to hemolysis. Choice C is incorrect as blood products are carefully screened for clots before distribution. Choice D is incorrect because it is not necessary for the recipient to eat before a blood transfusion.

3. A nurse is contributing to the plan of care for a client who is at risk of developing pressure injuries. Which of the following interventions should the nurse include?

• A. Place the client in a prone position
• B. Place the client in a 30-degree lateral position
• C. Encourage the client to reposition every 4 hours
• D. Place the client in a high Fowler's position

Correct answer: B

Rationale: The correct answer is B: Place the client in a 30-degree lateral position. Positioning the client laterally reduces pressure on bony prominences, improving circulation and helping prevent pressure injuries. Placing the client in a prone position (choice A) increases pressure on the bony prominences, raising the risk of pressure injuries. Similarly, placing the client in a high Fowler's position (choice D) can also increase pressure on certain areas. While encouraging the client to reposition every 4 hours (choice C) is important, the specific lateral positioning is more beneficial in preventing pressure injuries.

4. A client with a chest tube is post-op. What is the priority nursing action?

• A. Clamp the chest tube every 2 hours
• B. Check for air leaks and proper functioning of the chest tube
• C. Encourage deep breathing and coughing every 2 hours
• D. Encourage frequent coughing to clear secretions

Correct answer: B

Rationale: The correct answer is to check for air leaks and ensure the proper functioning of the chest tube. This action is crucial post-op to prevent complications such as pneumothorax or hemothorax. Clamping the chest tube every 2 hours (Choice A) is incorrect as it can lead to a buildup of pressure within the chest, risking complications. Encouraging deep breathing and coughing every 2 hours (Choice C) is important for respiratory hygiene but not the priority over ensuring the chest tube's proper function. Encouraging frequent coughing to clear secretions (Choice D) is not the priority when assessing a chest tube post-op; ensuring the chest tube's integrity and function take precedence.

5. Which intervention should be included for a client with heart failure?

• A. Encourage increased fluid intake
• B. Weigh the client daily to monitor fluid balance
• C. Restrict fluid intake during meals
• D. Limit daily activity to prevent fatigue

Correct answer: B

Rationale: Weighing the client daily to monitor fluid balance is crucial for clients with heart failure. This intervention helps assess for fluid retention or depletion, providing valuable information for managing the condition effectively. Encouraging increased fluid intake (Choice A) is contraindicated in heart failure as it can worsen fluid overload. Restricting fluid intake during meals (Choice C) may lead to dehydration, which is harmful for clients with heart failure. Limiting daily activity (Choice D) is not recommended as appropriate activity levels should be encouraged for overall well-being, under guidance to prevent excessive fatigue.

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