Nursing Elites

1. A patient with diabetes is admitted with high blood sugar levels. What is the nurse's priority intervention?

• A. Administer insulin as prescribed.
• B. Encourage the patient to exercise regularly.
• C. Encourage the patient to drink water.
• D. Provide the patient with a low-sugar diet.

Correct answer: A

Rationale: Administering insulin is the priority intervention for a patient admitted with high blood sugar levels because it helps lower the blood sugar levels effectively and rapidly. Insulin is a crucial medication for managing hyperglycemia in diabetes. Encouraging exercise (choice B) can be beneficial in the long term for managing blood sugar levels but is not the most immediate priority. While staying hydrated (choice C) is important, it is not the priority intervention when dealing with high blood sugar levels. Providing a low-sugar diet (choice D) is essential for long-term diabetes management but is not the immediate action needed to address high blood sugar levels in an admitted patient.

2. The nurse asks a client who is about to have a cardiac catheterization about any allergies. The client states, 'I always get a rash when I eat shellfish.' Which of the following is the priority nursing action?

• A. Attach a wristband indicating the client's allergy
• B. Ask the client if any other foods cause such a reaction
• C. Notify the dietary department of the client's allergy
• D. Notify the provider of the client's allergy

Correct answer: D

Rationale: Notifying the provider of the client's shellfish allergy is crucial to prevent a potential reaction from the contrast dye. While attaching a wristband indicating the allergy may be necessary, the priority is to inform the provider. Asking the client about other foods causing a similar reaction or notifying the dietary department, although important, are not the priority in this situation.

3. A healthcare professional is reviewing the medical record of a client who received their medications 1 hour ago. The client reports chest pain. This can be an adverse effect of what medication?

• A. Digoxin
• B. Albuterol
• C. Lisinopril
• D. Metoprolol

Correct answer: B

Rationale: The correct answer is B, Albuterol. Albuterol can cause chest pain as a side effect due to its beta-agonist effects, which can lead to chest discomfort. Digoxin (choice A) is not typically associated with causing chest pain. Lisinopril (choice C) and Metoprolol (choice D) are not known to commonly cause chest pain as a side effect.

4. Which of the following is a critical nursing action when managing a patient with a chest tube?

• A. Keep the chest tube clamped at all times.
• B. Ensure the chest tube is connected to a closed drainage system.
• C. Empty the chest tube drainage system every 2 hours.
• D. Disconnect the chest tube when the patient is ambulating.

Correct answer: B

Rationale: The correct answer is B: "Ensure the chest tube is connected to a closed drainage system." This is a critical nursing action when managing a patient with a chest tube because it is essential for proper drainage and to prevent complications such as air leaks or infections. Option A is incorrect because keeping the chest tube clamped at all times would prevent proper drainage and could lead to complications. Option C is incorrect as emptying the chest tube drainage system should be done based on assessment findings rather than a fixed time interval. Option D is incorrect because disconnecting the chest tube when the patient is ambulating can lead to complications like a pneumothorax.

5. A client with left hemiparesis is learning how to use a cane. Which of the following instructions should the nurse include?

• A. Place the cane approximately 61 cm (24 in) in front of their feet before advancing
• B. Advance the stronger leg and the cane together to support the weaker leg
• C. Remove the rubber tip when using the cane
• D. Hold the cane on the right side to provide support for the weaker leg

Correct answer: D

Rationale: The correct way to use a cane for a client with left hemiparesis is to hold the cane on the right side to provide support for the weaker left leg. This allows for better stability and weight distribution. Placing the cane approximately 61 cm (24 in) in front of their feet before advancing (Choice A) is not necessary and may lead to improper gait. Advancing the stronger leg and the cane together (Choice B) is incorrect as it does not provide support for the weaker leg. Removing the rubber tip when using the cane (Choice C) is also incorrect as the rubber tip helps provide traction and stability.

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