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. Select a myth or falsehood relating to pain, pain management, and addiction.

• A. Addiction can be accurately predicted.
• B. Withdrawal, drug tolerance, and physical dependence do not indicate addiction.
• C. Pain medications should be avoided in patients with a substance abuse history.
• D. Addiction is signaled by deception and stockpiling by the client.

Correct answer: A

Rationale: The correct answer is A because addiction cannot be accurately predicted. Choices B and C are incorrect. Withdrawal, drug tolerance, and physical dependence are not definitive signs of addiction, and pain medications can be used with patients who have a substance abuse history under careful monitoring. Choice D is incorrect because addiction is not solely signaled by deception and stockpiling; it is a complex condition with various behavioral, physical, and psychological aspects.

3. A nurse in the emergency department is assessing a client who is unconscious following a motor-vehicle crash. The client requires immediate surgery. Which of the following actions should the nurse take?

• A. Transport the client to the operating room without verifying informed consent
• B. Ask the anesthesiologist to sign the consent
• C. Obtain telephone consent from the facility administrator before the surgery
• D. Delay the surgery until the nurse can obtain informed consent

Correct answer: A

Rationale: In emergency situations where a client is unconscious and requires immediate surgery, implied consent applies. Implied consent allows healthcare providers, including nurses, to proceed with necessary treatment or surgery without formally verifying informed consent. Choice A is correct because the priority in this scenario is to ensure the client receives timely medical intervention to address life-threatening conditions. Choices B, C, and D are incorrect because in emergencies, waiting to obtain formal consent can delay critical treatment, risking the client's health and well-being.

4. What is an episiotomy?

• A. A surgical incision of the perineum to prevent tearing during delivery.
• B. Releasing the red plug from the cervix just before crowning occurs.
• C. An incision in the abdomen with which the baby can be delivered through.
• D. The severance of the umbilical cord between mother and child.

Correct answer: A

Rationale: An episiotomy is a surgical incision of the perineum to prevent tearing during delivery. This procedure is performed to widen the vaginal opening and facilitate childbirth. Choice B is incorrect as it describes the expulsion of the mucus plug, not an episiotomy. Choice C is incorrect as it refers to a different procedure, a cesarean section, where the baby is delivered through an incision in the abdomen. Choice D is incorrect as it pertains to cutting the umbilical cord, which is not related to an episiotomy.

5. Which nonpharmacological technique involves the use of electronic monitoring equipment while the patient controls basic bodily mechanisms?

• A. Meditation
• B. Visualization
• C. Biofeedback
• D. Chiropractic

Correct answer: C

Rationale: The correct answer is C: Biofeedback. Biofeedback is a nonpharmacological technique that uses electronic monitoring equipment to provide real-time data on physiological processes such as heart rate, muscle tension, and skin temperature. Through this feedback, patients learn to control and regulate these bodily functions voluntarily. Choice A, Meditation, involves focusing the mind and reducing stress through techniques like mindfulness or deep breathing, but it does not specifically rely on electronic monitoring equipment. Choice B, Visualization, is a technique where individuals imagine peaceful scenes to promote relaxation and reduce anxiety, and it also does not involve electronic monitoring. Choice D, Chiropractic, is a healthcare profession that focuses on the diagnosis and treatment of musculoskeletal disorders through manual adjustments and manipulation, which is unrelated to the use of electronic monitoring equipment for controlling bodily functions.

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