Nursing Elites

1. In a patient with diabetes, which of the following is a sign of hypoglycemia?

• A. Polydipsia
• B. Polyuria
• C. Dry skin
• D. Sweating

Correct answer: D

Rationale: Sweating is a common sign of hypoglycemia in patients with diabetes. When blood sugar levels drop too low, the body releases stress hormones like adrenaline, leading to symptoms such as sweating, shakiness, and palpitations. Polydipsia (excessive thirst) and polyuria (excessive urination) are more commonly associated with hyperglycemia (high blood sugar levels) in diabetes. Dry skin is not a typical symptom of hypoglycemia.

2. The healthcare provider is unable to palpate the client's left pedal pulses. Which of the following actions should the healthcare provider take next?

• A. Auscultate the pulses with a stethoscope.
• B. Call the physician.
• C. Use a Doppler ultrasound device.
• D. Inspect the lower left extremity.

Correct answer: C

Rationale: When pedal pulses are not palpable, using a Doppler ultrasound device is the appropriate next step to locate the pulse. Auscultating the pulses with a stethoscope (Choice A) is used for assessing blood flow in arteries above the clavicle, not for pedal pulses. Calling the physician (Choice B) may be necessary at a later stage, but initially, using a Doppler ultrasound device to locate the pulse is more appropriate. Inspecting the lower left extremity (Choice D) can provide visual information but will not help in locating the pedal pulses, making it a less suitable option.

3. An unlicensed assistive personnel (UAP) reports to the nurse that a client with a postoperative wound infection has a temperature of 103°F (39.4°C), blood pressure of 90/70, pulse of 124 beats/minute, and respirations of 28 breaths/minute. When assessing the client, findings include mottled skin appearance and confusion. Which action should the nurse take first?

• A. Transfer the client to the ICU.
• B. Initiate an infusion of intravenous (IV) fluids.
• C. Assess the client's core temperature.
• D. Obtain a wound specimen for culture.

Correct answer: B

Rationale: Initiating an infusion of IV fluids is the priority action to stabilize blood pressure in a client with signs of sepsis. Intravenous fluids help maintain perfusion to vital organs and prevent further deterioration. Option A is not the immediate priority as stabilizing the client's condition can be initiated in the current setting. Option C, assessing the client's core temperature, is important but not the most critical action at this time. Option D, obtaining a wound specimen for culture, is important for identifying the causative organism but is not the first priority in managing a client with signs of sepsis.

4. The nurse is caring for a patient who has recurrent urinary tract infections. The patient’s current infection is not responding to an antibiotic that has been used successfully several times in the past. The nurse understands that this is most likely due to

• A. acquired bacterial resistance.
• B. cross-resistance.
• C. inherent bacterial resistance.
• D. transferred resistance.

Correct answer: A

Rationale: The correct answer is A: acquired bacterial resistance. Acquired resistance happens when an organism has been exposed to the antibacterial drug, making it less effective over time. Cross-resistance (B) occurs when resistance to one drug leads to resistance to another. Inherent resistance (C) happens without prior exposure to the drug, meaning the bacteria are naturally resistant. Transferred resistance (D) involves the transfer of resistant genes from one organism to another, contributing to resistance development.

5. A client with stress incontinence is being taught about pelvic muscle exercises. Which statements should be included by the nurse? (Select all that apply.)

• A. Starting and stopping the urine stream involves using pelvic muscles.
• B. Tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
• C. Pelvic muscle exercises can be performed in various positions: lying down, sitting up, and standing.
• D. A & B

Correct answer: D

Rationale: The correct statements to include when teaching a client with stress incontinence about pelvic muscle exercises are that starting and stopping the urine stream involve using pelvic muscles and that tightening pelvic muscles for a slow count of 10 and then relaxing for a slow count of 10 can help strengthen them. It is essential to highlight that pelvic muscle exercises can be performed in various positions, including lying down, sitting up, and standing. This variety in positions helps engage the muscles effectively. Performing these exercises 15 times in each position can aid in strengthening the pelvic floor muscles. Consistent exercise over several weeks typically leads to improved control over urine leakage. Choice C is incorrect because pelvic muscle exercises can be performed in different positions and are not limited to sitting upright with feet on the floor.

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