Nursing Elites

1. Which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide (DiaBeta)?

• A. Administer glyburide again
• B. Administer subcutaneous insulin and monitor blood glucose
• C. Monitor blood glucose closely, and look for signs of hypoglycemia
• D. Monitor blood glucose and assess for signs of hyperglycemia

Correct answer: C

Rationale: After a client complains of nausea and vomits one hour after taking glyburide, the priority nursing intervention should be to monitor blood glucose closely and look for signs of hypoglycemia. Vomiting could indicate that the glyburide was not properly absorbed, potentially leading to hypoglycemia. Administering glyburide again (Choice A) could worsen hypoglycemia. Administering subcutaneous insulin (Choice B) is not appropriate without assessing the blood glucose first. Monitoring for signs of hyperglycemia (Choice D) is not the immediate concern in this situation.

2. A nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the physician, and the physician prescribes dietary instructions based on the sodium level. Which food item should the nurse instruct the client to avoid?

• A. Peas
• B. Cauliflower
• C. Low-fat yogurt
• D. Processed oat cereals

Correct answer: D

Rationale: The correct answer is processed oat cereals. Processed oat cereals are often high in sodium content, which should be avoided in cases of hypernatremia. Peas, cauliflower, and low-fat yogurt are generally low in sodium and are not typically contraindicated in hypernatremia. Therefore, choices A, B, and C are incorrect.

3. The wound irrigation process cleanses the wound and:

• A. Reduces the potential pain in the wound region or area.
• B. Stops the spread of infection by creating a 'clean' area.
• C. Pushes extravasated blood from a hematoma into nearby healthy tissue.
• D. Allows for the introduction of medications in solution form.

Correct answer: D

Rationale: The correct answer is D because wound irrigation allows for the introduction of medications in solution form to the wound site. Choice A is incorrect because while wound irrigation can help with pain management indirectly by promoting healing, its primary purpose is not to reduce pain directly. Choice B is incorrect as wound irrigation primarily aims to cleanse the wound and remove contaminants rather than creating a 'clean' area to stop infection spread. Choice C is incorrect because wound irrigation does not involve pushing extravasated blood from a hematoma into nearby healthy tissue; its main goal is to cleanse the wound and promote healing.

4. In developing a disaster management plan for a hospital, which resource should be the highest priority to have available in response to a bioterrorism event?

• A. A mental health specialist on the response team
• B. A sufficient supply of PPE
• C. A system for tracking client information
• D. A network for communication between staff members and families

Correct answer: B

Rationale: During a bioterrorism event, the highest priority resource to have available is a sufficient supply of personal protective equipment (PPE). PPE is crucial in protecting healthcare workers and other responders from exposure to biological agents. While mental health support, client information tracking systems, and communication networks are important components of disaster management, in the context of a bioterrorism event, ensuring the safety of staff through adequate PPE takes precedence over other resources.

5. Nurse Andy has finished teaching a client with diabetes mellitus how to administer insulin. He evaluates the learning has occurred when the client makes which statement?

• A. I should check my blood sugar immediately prior to the administration.
• B. I should provide direct pressure over the site following the injection.
• C. I should use the abdominal area only for insulin injections.
• D. I should only use a calibrated insulin syringe for the injections.

Correct answer: D

Rationale: The correct answer is D because using a calibrated insulin syringe is crucial for accurate dosing when administering insulin. Choice A is incorrect because checking blood sugar before administration is essential but not the specific evaluation of learning in this context. Choice B is incorrect as applying direct pressure over the injection site is not a key indicator of learning about insulin administration. Choice C is incorrect as insulin injections can also be administered in other sites like the thigh or arm; it is not limited to the abdominal area.

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