Nursing Elites

1. A nurse misreads a blood glucose level and administers excess insulin. What should the nurse monitor for?

• A. Monitor for hyperglycemia
• B. Monitor for hypoglycemia
• C. Administer glucose IV
• D. Monitor for increased thirst

Correct answer: B

Rationale: The correct answer is to monitor for hypoglycemia. Excess insulin can lead to low blood glucose levels, causing hypoglycemia. Symptoms of hypoglycemia include sweating, trembling, dizziness, confusion, and in severe cases, loss of consciousness. Options A, C, and D are incorrect because administering excess insulin would not lead to hyperglycemia or increased thirst, and administering glucose IV would exacerbate the issue by further lowering blood glucose levels.

2. A nurse is reviewing the medical record of a client who has unstable angina. Which of the following findings should the nurse report to the provider?

• A. Breath sounds
• B. Temperature
• C. Blood pressure
• D. Creatine kinase

Correct answer: A

Rationale: The correct answer is A: Breath sounds. When caring for a client with unstable angina, changes in breath sounds could indicate left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. Reporting any abnormalities in breath sounds promptly to the provider is crucial to prevent further complications. Choices B, C, and D are not directly related to the immediate management of unstable angina. Temperature, blood pressure, and creatine kinase levels are important parameters to monitor but are not the priority in this situation.

3. What dietary recommendations should be provided for a patient with pre-dialysis end-stage kidney disease?

• A. Reduce phosphorus intake to 700 mg/day
• B. Increase sodium intake
• C. Restrict protein intake to 0.55-0.60 g/kg/day
• D. Limit potassium-rich foods

Correct answer: A

Rationale: The correct recommendation for a patient with pre-dialysis end-stage kidney disease is to reduce phosphorus intake to 700 mg/day. Excessive phosphorus can be harmful to individuals with kidney disease as the kidneys may not be able to effectively remove it from the body. Choices B, C, and D are incorrect. Increasing sodium intake is generally not recommended for patients with kidney disease as it can lead to fluid retention and high blood pressure. Restricting protein intake is important in later stages of kidney disease, but for pre-dialysis end-stage kidney disease, protein intake should be individualized based on the patient's condition. Limiting potassium-rich foods is more relevant for patients with advanced kidney disease or those on dialysis, as impaired kidney function can lead to high potassium levels in the blood.

4. What are the expected manifestations of a thrombotic stroke?

• A. Gradual loss of function on one side of the body
• B. Loss of sensation in the affected extremity
• C. Sudden loss of consciousness
• D. Seizures and convulsions

Correct answer: A

Rationale: The correct answer is A: Gradual loss of function on one side of the body. Thrombotic strokes are caused by a clot forming in a blood vessel supplying the brain, leading to a gradual onset of symptoms due to impaired blood flow to specific brain regions. Choices B, C, and D are incorrect because loss of sensation, sudden loss of consciousness, seizures, and convulsions are not typically associated with thrombotic strokes. In a thrombotic stroke, the symptoms develop slowly over time, often over minutes to hours, and include manifestations such as weakness, numbness, or paralysis on one side of the body, along with other symptoms related to the affected brain area.

5. What is the priority intervention when a patient experiences abdominal cramping during enema administration?

• A. Lower the height of the enema solution container
• B. Stop the procedure and remove the tubing
• C. Continue the enema at a slower rate
• D. Increase the flow of the enema solution

Correct answer: A

Rationale: The correct answer is to lower the height of the enema solution container. This action can help relieve abdominal cramping by slowing the flow of the enema, reducing discomfort for the patient. Choice B, stopping the procedure and removing the tubing, is not the priority as adjusting the height of the container can often resolve the issue without needing to stop the procedure completely. Choice C, continuing the enema at a slower rate, may not address the immediate discomfort experienced by the patient. Choice D, increasing the flow of the enema solution, can exacerbate the cramping and should be avoided.

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