Nursing Elites

1. A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take?

• A. Document findings and continue to monitor the client.
• B. Contact the provider and recommend a 24-hour urine test.
• C. Review the client’s recent dietary selections.
• D. Perform a capillary artery glucose assessment.

Correct answer: D

Rationale: Glucose normally is not found in the urine. The normal renal threshold for glucose is about 220 mg/dL, which means that a person whose blood glucose is less than 220 mg/dL will not have glucose in the urine. A positive finding for glucose on urinalysis indicates high blood sugar. The most appropriate action would be to perform a capillary artery glucose assessment. The client needs further evaluation for this abnormal result; therefore, documenting and continuing to monitor is not appropriate. Requesting a 24-hour urine test or reviewing the client’s dietary selections will not assist the nurse to make a clinical decision related to this abnormality.

2. What is the primary purpose of administering IV fluids to a patient in septic shock?

• A. To reduce blood pressure.
• B. To increase cardiac output.
• C. To stabilize blood glucose levels.
• D. To maintain adequate tissue perfusion.

Correct answer: D

Rationale: The primary purpose of administering IV fluids to a patient in septic shock is to maintain adequate tissue perfusion. In septic shock, there is a significant drop in blood pressure and systemic vascular resistance leading to poor tissue perfusion. IV fluids help to restore intravascular volume, improve perfusion to vital organs, and prevent organ failure. Choice A ('To reduce blood pressure') is incorrect because IV fluids in septic shock aim to restore tissue perfusion rather than lower blood pressure. Choice B ('To increase cardiac output') is incorrect as the primary goal is to improve tissue perfusion, not specifically increase cardiac output. Choice C ('To stabilize blood glucose levels') is unrelated to the primary purpose of administering IV fluids in septic shock, which is to address the compromised tissue perfusion.

3. A client with diabetes mellitus who is taking NPH insulin (Humulin N) in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. What intervention should the nurse recommend to help prevent hypoglycemia while the client is sleeping?

• A. Eat a bedtime snack.
• B. Avoid physical activity.
• C. Take half the usual dose of insulin.
• D. Discontinue insulin until the next meal.

Correct answer: A

Rationale: Eating a bedtime snack is the most appropriate intervention to prevent hypoglycemia during the night when NPH insulin peaks. This snack helps maintain blood glucose levels and counteracts the risk of hypoglycemia. Avoiding physical activity is not recommended as it can further lower blood sugar levels. Taking half the usual dose of insulin can lead to inadequate control of blood sugar levels. Discontinuing insulin until the next meal can result in uncontrolled hyperglycemia, especially during the peak action of NPH insulin.

4. The nurse is monitoring a client who is receiving continuous ambulatory peritoneal dialysis. The nurse should notify the physician of which of the following findings?

• A. Clear dialysate outflow.
• B. Cloudy dialysate outflow.
• C. Decreased urine output.
• D. Increased blood pressure.

Correct answer: B

Rationale: Cloudy dialysate outflow is an indication of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Clear dialysate outflow is a normal finding indicating proper dialysis function and should not raise concern. Decreased urine output may be expected in a client undergoing dialysis due to the removal of excess fluids from the body. Increased blood pressure is a common complication in clients with kidney disease but is not directly related to cloudy dialysate outflow.

5. An 81-year-old male client has emphysema. He lives at home with his cat and manages self-care with no difficulty. When making a home visit, the nurse notices that his tongue is somewhat cracked, and his eyeballs are sunken into his head. What nursing intervention is indicated?

• A. Help the client determine ways to increase his fluid intake.
• B. Obtain an appointment for the client to see a pulmonologist.
• C. Schedule an appointment with a nutritionist to assess the client's diet.
• D. Encourage the client to slightly increase his use of oxygen at night and to always use humidified oxygen.

Correct answer: A

Rationale: The correct nursing intervention in this scenario is to assist the client in finding ways to increase his fluid intake. Clients with COPD, including emphysema, should aim to consume at least three liters of fluids per day to help keep their mucus thin. As the disease progresses, these clients may decrease fluid intake due to various reasons. Suggesting creative methods, such as having disposable fruit juices readily available, can help the client meet this goal. Option B is incorrect as seeing an ear, nose, and throat specialist is not directly related to the client's symptoms. Option C is not the priority in this case, as the main concern is addressing the client's dehydration. Option D does not address the immediate need for managing the client's dehydration and is not the most appropriate intervention at this time.

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