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. The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the client’s recent history?

• A. Pyelonephritis
• B. Myocardial infarction
• C. Bladder cancer
• D. Kidney stones

Correct answer: B

Rationale: In pre-renal acute kidney injury, there is a decrease in perfusion to the kidneys. Myocardial infarction can lead to decreased blood flow to the kidneys, causing pre-renal AKI. Pyelonephritis is an intrinsic/intrarenal cause of AKI involving kidney damage. Bladder cancer and kidney stones are post-renal causes of AKI due to urinary flow obstruction, not related to perfusion issues seen in pre-renal AKI.

3. The client with chronic renal failure is receiving peritoneal dialysis. Which of the following is the most important action for the nurse to take?

• A. Administer the prescribed antibiotics.
• B. Monitor for signs of infection.
• C. Encourage the client to increase fluid intake.
• D. Monitor the client's weight daily.

Correct answer: B

Rationale: Monitoring for signs of infection is crucial in clients undergoing peritoneal dialysis. Peritonitis is a severe complication associated with peritoneal dialysis, making it essential to promptly identify any signs of infection, such as abdominal pain, cloudy dialysate, fever, and an elevated white blood cell count. Administering antibiotics without proper assessment can lead to antibiotic resistance and should not be the initial action. Encouraging increased fluid intake may not be appropriate without assessing the client's fluid status. Monitoring weight alone does not address the immediate risk of peritonitis in a client undergoing peritoneal dialysis.

4. A 58-year-old client who has been post-menopausal for five years is concerned about the risk for osteoporosis because her mother has the condition. Which information should the nurse offer?

• A. Osteoporosis is a progressive genetic disease with no effective treatment.
• B. Calcium loss from bones can be slowed by increasing calcium intake and exercise.
• C. Estrogen replacement therapy should be started to prevent the progression of osteoporosis.
• D. Low-dose corticosteroid treatment effectively halts the course of osteoporosis.

Correct answer: B

Rationale: Post-menopausal females are at risk for osteoporosis due to the cessation of estrogen secretion. While genetics can play a role, osteoporosis is not solely a genetic disease. Increasing calcium intake, along with vitamin D supplementation and weight-bearing exercise, can help prevent further bone loss by slowing down calcium loss from bones. Estrogen replacement therapy is no longer recommended as a first-line treatment for osteoporosis due to associated risks. Corticosteroid treatment is not typically used as a primary treatment for osteoporosis.

5. In a client with heart failure presenting bilateral +4 edema of the right ankle extending up to midcalf while sitting with legs dependent, what is the priority goal?

• A. Decrease venous congestion.
• B. Maintain normal respirations.
• C. Maintain body temperature.
• D. Prevent injury to lower extremities.

Correct answer: A

Rationale: The priority goal in this scenario is to decrease venous congestion. By elevating the legs above the heart level, venous return is improved, reducing congestion in the lower extremities. This intervention helps decrease swelling and prevents complications such as impaired tissue perfusion. Maintaining normal respirations and body temperature are important aspects of care but are secondary to addressing the immediate issue of venous congestion. Preventing injury to lower extremities is also essential but takes precedence after managing the venous congestion to prevent further complications.

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