Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient with Type 2 diabetes is brought into the emergency room in an unresponsive state.
Vital signs include BP: 88/56, HR: 122, RR 16, Sp 95% and glucose of 720 mg/dL. A diagnosis of Hyperosmolar Hyperglycemic Syndrome (HHS) is made.The nurse prepares for the administration of which priority therapy?
A. Administration of Glucagon.
Administration of Glucagon is not the primary treatment for HHS. Glucagon is a hormone that raises blood glucose levels and would not be beneficial in a situation where blood glucose is already extremely high.
B. Dextrose 50%.
Dextrose 50% is a concentrated glucose solution and would not be appropriate in the treatment of HHS, where blood glucose levels are already dangerously high.
C. 0.45% Normal Saline IV.
While IV fluids are a crucial part of the treatment for HHS, 0.45% Normal Saline (also known as half-normal saline) is a hypotonic solution and is not typically the first choice for fluid resuscitation in HHS. The preferred initial fluid is often 0.9% saline (normal saline), which is isotonic.
D. 0.9% saline solution IV.
Hyperosmolar Hyperglycemic Syndrome (HHS) is a serious complication of diabetes that occurs when blood sugar levels are extremely high. The primary treatment for HHS is intravenous fluids and insulin. Specifically, 0.9% saline solution IV is often used initially to restore volume and correct severe dehydration.
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Full Explanation
Choice D rationale
Hyperosmolar Hyperglycemic Syndrome (HHS) is a serious complication of diabetes that occurs when blood sugar levels are extremely high. The primary treatment for HHS is intravenous fluids and insulin. Specifically, 0.9% saline solution IV is often used initially to restore volume and correct severe dehydration.
Choice A rationale
Administration of Glucagon is not the primary treatment for HHS. Glucagon is a hormone that raises blood glucose levels and would not be beneficial in a situation where blood glucose is already extremely high.
Choice B rationale
Dextrose 50% is a concentrated glucose solution and would not be appropriate in the treatment of HHS, where blood glucose levels are already dangerously high.
Choice C rationale
While IV fluids are a crucial part of the treatment for HHS, 0.45% Normal Saline (also known as half-normal saline) is a hypotonic solution and is not typically the first choice for fluid resuscitation in HHS. The preferred initial fluid is often 0.9% saline (normal saline), which is isotonic.
Similar Questions
The nurse is evaluating the patient’s response to antibiotic therapy. Which data would indicate that the medication has been effective?
A. Decrease in inflammation at the site of infection.
A decrease in inflammation at the site of infection is a key indicator that antibiotic therapy is effective. Inflammation is a response to infection, so if the inflammation is reducing, it suggests that the infection is being successfully treated.
B. Increase in circulating neutrophils.
An increase in circulating neutrophils could indicate an ongoing response to infection, rather than resolution. Neutrophils are a type of white blood cell that the body produces more of when there’s an infection. Therefore, an increase in neutrophils does not necessarily indicate that the antibiotic therapy has been effective.
C. Positive culture and sensitivity report.
A positive culture and sensitivity report indicates the presence of bacteria and identifies which antibiotics the bacteria are sensitive to. While this information is crucial for selecting the most effective antibiotic, it does not indicate whether the chosen antibiotic therapy has been effective.
D. Symptomatic fever.
A symptomatic fever could indicate an ongoing infection, rather than resolution. While fever can decrease as an infection is brought under control, the presence of a symptomatic fever does not necessarily indicate that the antibiotic therapy has been effective.
Full Explanation
Choice A rationale
A decrease in inflammation at the site of infection is a key indicator that antibiotic therapy is effective. Inflammation is a response to infection, so if the inflammation is reducing, it suggests that the infection is being successfully treated.
Choice B rationale
An increase in circulating neutrophils could indicate an ongoing response to infection, rather than resolution. Neutrophils are a type of white blood cell that the body produces more of when there’s an infection. Therefore, an increase in neutrophils does not necessarily indicate that the antibiotic therapy has been effective.
Choice C rationale
A positive culture and sensitivity report indicates the presence of bacteria and identifies which antibiotics the bacteria are sensitive to. While this information is crucial for selecting the most effective antibiotic, it does not indicate whether the chosen antibiotic therapy has been effective.
Choice D rationale
A symptomatic fever could indicate an ongoing infection, rather than resolution. While fever can decrease as an infection is brought under control, the presence of a symptomatic fever does not necessarily indicate that the antibiotic therapy has been effective.
A patient is receiving gentamicin every 12 hours IVPB for an infection.
The nurse has administered the 0900 dose, which is prescribed to run over 1 hour. The physician prescribed peak and trough levels to be drawn.
When should the nurse expect to draw the peak level?
A. 0930
Drawing the peak level at 0930, which is 30 minutes after the start of the infusion, would be too early. The medication would not have had enough time to reach its peak level in the blood.
B. 1000
The peak level of gentamicin is typically evaluated 30 minutes after the completion of the infusion. Since the infusion is administered over 1 hour, the peak level would be expected to be drawn at 10001.
C. 2030
Drawing the peak level at 2030, which is 12 hours after the start of the infusion, would not provide an accurate representation of the peak level of gentamicin. This is because the medication would have been metabolized and excreted over this period.
D. 2100
Drawing the peak level at 2100, which is 12.5 hours after the start of the infusion, would not provide an accurate representation of the peak level of gentamicin. This is because the medication would have been metabolized and excreted over this period.
Full Explanation
Choice A rationale
Drawing the peak level at 0930, which is 30 minutes after the start of the infusion, would be too early. The medication would not have had enough time to reach its peak level in the blood.
Choice B rationale
The peak level of gentamicin is typically evaluated 30 minutes after the completion of the infusion. Since the infusion is administered over 1 hour, the peak level would be expected to be drawn at 10001.
Choice C rationale
Drawing the peak level at 2030, which is 12 hours after the start of the infusion, would not provide an accurate representation of the peak level of gentamicin. This is because the medication would have been metabolized and excreted over this period.
Choice D rationale
Drawing the peak level at 2100, which is 12.5 hours after the start of the infusion, would not provide an accurate representation of the peak level of gentamicin. This is because the medication would have been metabolized and excreted over this period.
A patient has been receiving warfarin sodium 2.5 mg PO daily for four days and the International Normalized Ratio (INR) is 1.9. What should be the nurse’s next step?
A. Place the patient back on the heparin infusion and redraw laboratory values.
Placing the patient back on the heparin infusion and redrawing laboratory values would not be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, the warfarin therapy is not yet fully effective, and there is no need to revert to heparin.
B. Ask the healthcare provider if the patient’s medication can be changed to rivaroxaban.
Asking the healthcare provider if the patient’s medication can be changed to rivaroxaban would not be the appropriate next step. Rivaroxaban is a different type of anticoagulant and would not necessarily be more effective in this situation.
C. Notify the healthcare provider and ask if the dose of warfarin can be increased.
Notifying the healthcare provider and asking if the dose of warfarin can be increased would be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, an increase in the warfarin dose may be necessary to achieve therapeutic anticoagulation.
D. Prepare to administer a dose of Vitamin K subcutaneously.
Preparing to administer a dose of Vitamin K subcutaneously would not be the appropriate next step. Vitamin K is used to reverse the effects of warfarin and would be counterproductive in this situation.
Full Explanation
Choice A rationale
Placing the patient back on the heparin infusion and redrawing laboratory values would not be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, the warfarin therapy is not yet fully effective, and there is no need to revert to heparin.
Choice B rationale
Asking the healthcare provider if the patient’s medication can be changed to rivaroxaban would not be the appropriate next step. Rivaroxaban is a different type of anticoagulant and would not necessarily be more effective in this situation.
Choice C rationale
Notifying the healthcare provider and asking if the dose of warfarin can be increased would be the appropriate next step. The INR of 1.9 is below the therapeutic range of 2.0 - 3.0 for most patients on warfarin. Therefore, an increase in the warfarin dose may be necessary to achieve therapeutic anticoagulation.
Choice D rationale
Preparing to administer a dose of Vitamin K subcutaneously would not be the appropriate next step. Vitamin K is used to reverse the effects of warfarin and would be counterproductive in this situation.