Nursing Elites

1. The nurse is caring for a 69-year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Test blood sugar every 2 hours using Accu-Chek
• B. Review signs of hyperglycemia with the family and client
• C. Administer insulin if the blood sugar is elevated
• D. Measure the client's urine output

Correct answer: D

Rationale: The correct answer is D because measuring urine output is a task that falls within the UAP's scope of practice and does not require clinical decision-making. Choice A is incorrect because testing blood sugar using Accu-Chek involves interpreting results and possible adjustments, which require a licensed healthcare provider. Choice B is incorrect as discussing signs of hyperglycemia involves education and interpretation that should be done by a nurse. Choice C is incorrect since administering insulin is a high-risk task that necessitates precise dosing and monitoring, thus should not be delegated to UAP.

2. A 4-year-old child is returned to the room following a tonsillectomy and adenoidectomy. Which of the following assessments would require the nurse's immediate attention?

• A. Frequent swallowing
• B. Coughing
• C. Slow breathing
• D. Tachycardia

Correct answer: A

Rationale: In a post-tonsillectomy and adenoidectomy patient, frequent swallowing is a crucial assessment that requires immediate attention by the nurse. Frequent swallowing can indicate bleeding, a complication that needs urgent intervention. Coughing may be expected due to irritation from the surgery but is not as concerning as potential bleeding. Slow breathing and tachycardia are not typically immediate concerns following this type of surgery.

3. A client with Type 2 diabetes is admitted with frequent hyperglycemic episodes and glycosylated hemoglobin (A1C) of 10%. What actions should the nurse include in the client's plan of care?

• A. Mixing glargine with aspart insulin to manage glucose levels.
• B. Teaching foot care to prevent injuries.
• C. Coordinating carbohydrate-controlled meals and subcutaneous injections.
• D. Reviewing site rotation for insulin injections.

Correct answer: C

Rationale: In managing a client with Type 2 diabetes experiencing frequent hyperglycemic episodes and with a high A1C level, it is crucial to coordinate carbohydrate-controlled meals and subcutaneous injections. This approach helps regulate blood glucose levels effectively. Mixing glargine with aspart insulin (Choice A) is not a recommended practice as these insulins have different onset and peak times. Teaching foot care (Choice B) is important in diabetes management but is not the priority in this scenario. Reviewing site rotation for insulin injections (Choice D) is important to prevent lipodystrophy but is not the immediate action needed to address the client's hyperglycemia and high A1C level.

4. A client with Type 1 diabetes reports feeling shaky and lightheaded. The nurse checks the client's blood glucose level and it is 60 mg/dL. What action should the nurse take first?

• A. Give the client a glucagon injection
• B. Encourage the client to eat a high-protein snack
• C. Recheck the blood glucose level in 15 minutes
• D. Administer 15 grams of a fast-acting carbohydrate

Correct answer: D

Rationale: The correct answer is D: Administer 15 grams of a fast-acting carbohydrate. The first step in treating hypoglycemia is to quickly raise the client's blood sugar level. Fast-acting carbohydrates like glucose tablets or juice are essential for this purpose. Giving a glucagon injection is typically reserved for severe hypoglycemia when the client is unable to take anything by mouth. Encouraging the client to eat a high-protein snack is not appropriate for immediate treatment of hypoglycemia. Rechecking the blood glucose level in 15 minutes is important after administering the fast-acting carbohydrate to ensure that the blood sugar has returned to a safe level.

5. A client with a history of chronic kidney disease presents with increased swelling and shortness of breath. What is the nurse's priority action?

• A. Administer oxygen at 2 liters per nasal cannula.
• B. Administer a diuretic as prescribed.
• C. Monitor the client's vital signs.
• D. Reposition the client to improve lung expansion.

Correct answer: B

Rationale: The correct answer is to administer a diuretic as prescribed. In a client with chronic kidney disease experiencing increased swelling and shortness of breath, the priority action is to address fluid retention. Administering a diuretic helps reduce fluid overload, alleviate symptoms, and prevent complications associated with fluid buildup. Option A is not the priority in this situation as addressing fluid retention takes precedence over providing oxygen. While monitoring vital signs is important, it is secondary to addressing the underlying cause of symptoms. Repositioning the client may help with comfort but does not directly address the fluid overload seen in chronic kidney disease.

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