Nursing Elites

1. What is the most common symptom of hypoglycemia that the nurse should teach the diabetic client to recognize?

• A. Nervousness
• B. Anorexia
• C. Kussmaul's respirations
• D. Bradycardia

Correct answer: A

Rationale: Nervousness is the most common symptom of hypoglycemia. It is often accompanied by other signs such as weakness, perspiration, confusion, and palpitations. Anorexia (lack of appetite) is not a typical symptom of hypoglycemia; it is more commonly associated with hyperglycemia. Kussmaul's respirations are a deep and labored breathing pattern seen in diabetic ketoacidosis, not hypoglycemia. Bradycardia (slow heart rate) is not a typical symptom of hypoglycemia; tachycardia (fast heart rate) is more commonly associated with hypoglycemia due to the release of catecholamines in response to low blood sugar.

2. A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

• A. Carbon dioxide is converted in the kidneys for elimination.
• B. Blood oxygen levels are stimulating the respiratory rate.
• C. Hyperventilation is eliminating carbon dioxide rapidly.
• D. High levels of carbon dioxide have accumulated in the blood.

Correct answer: D

Rationale: The correct answer is D. High levels of carbon dioxide in the blood are indicative of respiratory acidosis, often due to inadequate ventilation. In respiratory acidosis, there is retention of carbon dioxide (hypercapnia) leading to an increase in carbonic acid levels in the blood, resulting in an acidic pH. Option A is incorrect because carbon dioxide elimination primarily occurs through the lungs, not the kidneys. Option B is incorrect because blood oxygen levels primarily affect the respiratory rate to regulate oxygen levels, not carbon dioxide levels. Option C is incorrect because hyperventilation would lead to a decrease, not an increase, in carbon dioxide levels.

3. A client expresses difficulty voiding in public places. How should the nurse respond?

• A. Offer to turn on the faucet in the bathroom to help stimulate urination.
• B. Suggest a prescription for a diuretic to increase urine output.
• C. Propose moving to a room with a private bathroom to enhance comfort.
• D. Close the curtain to provide maximum privacy.

Correct answer: D

Rationale: The nurse should prioritize the client's privacy when addressing issues related to voiding discomfort in public places. Closing the curtain in the current room would offer immediate privacy and support the client's needs. Turning on the faucet is not an evidence-based intervention for voiding difficulties. Prescribing a diuretic is not appropriate without further assessment. While moving to a room with a private bathroom might be ideal, it may not be immediately feasible, making ensuring privacy in the current setting the most appropriate action.

4. A nurse cares for a client with urinary incontinence. The client states, “I am so embarrassed. My bladder leaks like a young child’s bladder.” How should the nurse respond?

• A. I understand how you feel. I would be mortified.
• B. Incontinence pads will minimize leaks in public.
• C. I can teach you strategies to help control your incontinence.
• D. More women experience incontinence than you might think.

Correct answer: C

Rationale: The nurse should accept and acknowledge the client’s concerns, and assist the client to learn techniques that will allow control of urinary incontinence. The nurse should not diminish the client’s concerns with the use of pads or stating statistics about the occurrence of incontinence.

5. The nurse notes that the only ECG for a 55-year-old male client scheduled for surgery in two hours is dated two years ago. The client reports that he has a history of 'heart trouble,' but has no problems at present. Hospital protocol requires that those over 50 years of age have a recent ECG prior to surgery. What nursing action is best for the nurse to implement?

• A. Ask the client to explain what he means by 'heart trouble.'
• B. Call for an ECG to be performed immediately.
• C. Notify surgery that the ECG is over two years old.
• D. Notify the client's surgeon immediately.

Correct answer: B

Rationale: In this scenario, the client is 55 years old with a history of 'heart trouble,' which necessitates a recent ECG before surgery as per hospital policy. The nurse should prioritize patient safety and adhere to the protocol by arranging for an ECG to be performed immediately. Option A is not the best initial action as the focus should be on obtaining the necessary test first. Option C is not the immediate action required, and option D is premature without obtaining the necessary ECG first.

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