Nursing Elites

1. When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:

• A. one commercially prepared glucose tablet
• B. two hard candies
• C. 4-6 ounces of fruit juice
• D. 2-3 teaspoons of honey

Correct answer: D

Rationale: The correct immediate intervention for hypoglycemia is to provide 10-15 grams of fast-acting simple carbohydrates orally if the client is conscious and able to swallow. This can be achieved by giving 2-3 teaspoons of honey. Honey is a quick source of simple sugars that can rapidly raise blood glucose levels. Commercially prepared glucose tablets or 4-6 ounces of fruit juice are also appropriate options. However, adding sugar to fruit juice is unnecessary as the natural fruit sugar in juice already provides enough simple carbohydrates to raise blood glucose levels. Hard candies are not the best choice for immediate intervention in hypoglycemia as they may not provide a sufficient amount of fast-acting carbohydrates needed to raise blood sugar levels quickly.

2. What advice should be given to a client with stress incontinence?

• A. to consider trying Kegel exercises
• B. to undergo surgery immediately
• C. to avoid all forms of treatment
• D. to ignore the issue as it is not serious

Correct answer: A

Rationale: For stress incontinence, advising the client to consider trying Kegel exercises is appropriate. Kegel exercises involve tightening and releasing the pelvic floor muscles, which can improve stress incontinence by strengthening the muscles that control urination. Choice B suggesting immediate surgery is incorrect as surgery is usually considered after conservative treatments like Kegel exercises have been tried. Choice C advising to avoid all forms of treatment is dangerous and neglectful. Choice D recommending to ignore the issue is inappropriate as it can impact the client's quality of life and may worsen over time without intervention.

3. A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:

• A. fluid volume excess.
• B. hyperkalemia.
• C. hypercalcemia.
• D. fluid volume deficit.

Correct answer: D

Rationale: Elevated urine osmolarity indicates that the urine is concentrated, suggesting the body is trying to conserve water. This commonly occurs in conditions like dehydration or fluid volume deficit. Assessing the client for fluid volume excess, hyperkalemia, or hypercalcemia would not be the priority in this situation. Therefore, the correct answer is to assess the client for fluid volume deficit. Fluid volume excess is characterized by decreased urine osmolarity, while hyperkalemia and hypercalcemia are related to electrolyte imbalances and would not directly cause elevated urine osmolarity.

4. A patient has a history of cardiac arrhythmia. A nurse has been ordered to give 2 units of blood to this patient. The nurse should take which of the following actions?

• A. Administer pain medication to the patient.
• B. Inform the patient's family about the procedure in person.
• C. Decrease the temperature of the blood to be given.
• D. Increase the temperature of the blood to be given.

Correct answer: D

Rationale: In patients with a history of cardiac arrhythmia, warming the blood before transfusion can help prevent additional arrhythmias. Cold blood can lead to arrhythmias and should be avoided. Administering pain medication (Choice A) is not directly related to the safe administration of blood. Informing the patient's family in person (Choice B) is important but not the immediate action required for safe transfusion. Decreasing the temperature of the blood to be given (Choice C) would increase the risk of cardiac arrhythmia, contrary to the goal of ensuring patient safety.

5. Why is it often necessary to draw a complete blood count and differential (CBC/differential) when a client is being treated with an antiepileptic drug (AED)?

• A. The hematocrit is adversely affected due to increased vascular volume.
• B. AEDs can lead to blood dyscrasia as a side effect.
• C. AEDs may cause aplastic anemia and megaloblastic anemia.
• D. Some AEDs induce white blood cell reduction.

Correct answer: B

Rationale: When a client is being treated with antiepileptic drugs (AEDs), it is essential to monitor for potential side effects on blood parameters. Some AEDs can lead to blood dyscrasia, which includes conditions like aplastic anemia and megaloblastic anemia. Therefore, drawing a complete blood count and differential helps in identifying these adverse effects early. Choices A, C, and D are incorrect because the primary concern when monitoring blood parameters in clients on AEDs is the risk of blood dyscrasia, not changes in hematocrit due to vascular volume, white blood cell reduction, or immune modulation.

Similar Questions