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. A nurse is caring for her clients when her new admit arrives on the unit. What action by the nurse is most appropriate?

• A. Ask the nursing assistant to complete emptying the catheter bag and assess the new admission.
• B. Ask the nursing assistant to take vital signs on the new admit and begin the history until she can get there.
• C. Ask the graduate nurse on the floor to initiate the assessment process until she can get there.
• D. Ask the unit secretary to make the client and family comfortable until she can complete her present task.

Correct answer: C

Rationale: The most appropriate action for the nurse in this situation is to ask the graduate nurse on the floor to initiate the assessment process until she can arrive. Nursing assistants are not qualified to perform assessments, and the unit secretary's role does not involve client assessments. Delegating the assessment to the graduate nurse ensures that a qualified healthcare professional is evaluating the new admission, aligning with the nurse's responsibilities and providing appropriate care.

3. The drug of choice to decrease uric acid levels is:

• A. prednisone (Colisone)
• B. allopurinol (Zyloprim)
• C. indomethacin (Indocin)
• D. hydrochlorothiazide (HydroDiuril)

Correct answer: B

Rationale: The correct answer is allopurinol (Zyloprim) as it is a xanthine oxidase inhibitor that decreases uric acid formation. Allopurinol is commonly used to manage gout by lowering uric acid levels. Prednisone is a corticosteroid used to decrease inflammation, not to lower uric acid levels. Indomethacin is an analgesic, anti-inflammatory, and antipyretic agent, but it is not the drug of choice for lowering uric acid levels. Hydrochlorothiazide is a thiazide diuretic used to treat hypertension and edema, not to decrease uric acid levels.

4. The nurse is caring for a client complaining of intense headaches with increasing pain for the past one month. An MRI is ordered. In reviewing the client's information, which piece of information is of concern?

• A. Allergy to shellfish
• B. Has a cardiac pacemaker
• C. A diabetic
• D. No IV access

Correct answer: B

Rationale: The correct answer is 'Has a cardiac pacemaker.' If a client with a cardiac pacemaker undergoes an MRI, the magnetic field can interfere with the pacemaker's function, leading to serious complications or even death. It is crucial to ensure that the pacemaker is compatible with MRI imaging or to consider alternative imaging modalities. The other choices, such as 'Allergy to shellfish,' 'A diabetic,' and 'No IV access,' are not direct contraindications for an MRI scan and do not pose the same level of risk as having a cardiac pacemaker.

5. Which of the following needs immediate medical attention and emergency intervention? The client who:

• A. complains of sharp pain upon taking a deep breath and excessive coughing.
• B. exhibits yellow, productive sputum, low-grade fever, and crackles.
• C. has a shift of the trachea to the left, with no breath sounds on the right.
• D. has asthma and complains of an inability to catch her breath after exercise.

Correct answer: C

Rationale: Choice C is indicative of a tension pneumothorax, which is considered a medical emergency. The respiratory system is severely compromised, and venous return to the heart is affected. The mediastinal shift is to the unaffected side, indicating a critical situation that requires immediate intervention to prevent further deterioration. This condition can rapidly progress to a life-threatening state, necessitating prompt medical attention. Choices A, B, and D do not present with life-threatening conditions requiring emergency intervention. Choice A mentions symptoms of pleurisy, which may be painful but not immediately life-threatening. Choice B describes symptoms of bronchitis, which may require medical attention but not of an emergent nature. Choice D reflects a common complaint in asthma but does not suggest an immediate life-threatening situation unless severe respiratory distress is present.

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