Nursing Elites

1. The nurse is instructing the client on insulin administration. The client's morning dose of insulin is 10 units of regular and 22 units of NPH. The nurse checks the dose accuracy with the client. The nurse determines that the client has prepared the correct dose when the syringe reads how many units?

• A. 10 units.
• B. 22 units.
• C. 32 units.
• D. 24 units.

Correct answer: C

Rationale: The correct dose would be 32 units, which is the sum of 10 units of regular insulin and 22 units of NPH. It is essential to combine the doses of both types of insulin to ensure the client administers the correct total dose. Choices A and B represent the individual doses of regular and NPH insulin, respectively, not the combined total. Choice D is incorrect as it does not reflect the sum of both insulin doses.

2. What is the most common cause of coronary artery disease?

• A. Atherosclerosis.
• B. Hyperlipidemia.
• C. Diabetes.
• D. Smoking.

Correct answer: A

Rationale: The correct answer is Atherosclerosis. It is the primary cause of coronary artery disease, as it involves the buildup of plaque in the arteries, restricting blood flow to the heart. Hyperlipidemia (choice B) contributes to atherosclerosis by increasing cholesterol levels in the blood but is not the direct cause of coronary artery disease. Diabetes (choice C) can accelerate atherosclerosis due to high blood sugar levels, but it is not the most common cause. Smoking (choice D) is a significant risk factor for developing coronary artery disease but is not the primary cause.

3. A client with Diabetes Insipidus (DI) is being cared for by a nurse. Which data warrants the most immediate intervention by the nurse?

• A. Serum sodium of 185 mEq/L (185 mmol/L)
• B. Dry skin with poor skin turgor
• C. Apical rate of 110 beats per minute
• D. Polyuria and excessive thirst

Correct answer: A

Rationale: A serum sodium level of 185 mEq/L (185 mmol/L) is dangerously high and indicates severe dehydration, requiring immediate intervention to prevent neurological damage. The other options are not as critical as high serum sodium levels, which can lead to serious complications such as seizures, coma, and death if not promptly addressed. Dry skin with poor skin turgor and polyuria with excessive thirst are common findings in clients with Diabetes Insipidus and should be managed but do not pose an immediate threat to the client's life. An apical heart rate of 110 beats per minute may indicate tachycardia, which could be related to dehydration but is not as urgent as addressing the severe hypernatremia.

4. A healthcare professional is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the healthcare professional to suspect that the oxygen saturation readings are not entirely accurate?

• A. Infection
• B. Hypertension
• C. Low blood pressure
• D. Loss of cough reflex

Correct answer: C

Rationale: Low blood pressure (hypotension), shock, and the use of peripheral vasoconstricting medications can lead to inaccurate pulse oximetry readings due to impaired peripheral perfusion. Hypertension and infection are not typically associated with inaccurate pulse oximetry readings, while the loss of cough reflex does not directly affect oxygen saturation readings.

5. A nurse has a prescription to discontinue a client’s nasogastric tube. The nurse auscultates the client’s bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and:

• A. Exhale during tube removal
• B. Bear down during tube removal
• C. Hold the breath during tube removal
• D. Breathe normally during tube removal

Correct answer: C

Rationale: The correct answer is to instruct the client to hold their breath during tube removal. This is because the airway may be temporarily obstructed during the removal process. By holding their breath, the client can help prevent aspiration or discomfort during the removal of the nasogastric tube. Choices A, B, and D are incorrect because exhaling, bearing down, or breathing normally during tube removal may not provide the necessary protection against aspiration or discomfort that holding the breath does.

Similar Questions