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A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?
- A. Administer intravenous insulin as prescribed.
- B. Monitor the client's urine output.
- C. Administer intravenous fluids.
- D. Administer 50% dextrose IV push.
Correct Answer: A
Rationale: Administering intravenous insulin is the initial priority in managing diabetic ketoacidosis (DKA). Insulin helps to reduce blood glucose levels and correct metabolic acidosis, addressing the underlying cause of DKA. Monitoring urine output (choice B) is important but is not the first intervention needed. Administering intravenous fluids (choice C) is essential to correct dehydration in DKA, but insulin therapy takes precedence. Administering 50% dextrose IV push (choice D) is contraindicated in DKA as it can exacerbate hyperglycemia.
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A client who developed syndrome of inappropriate antidiuretic hormone (SIADH) associated with small carcinoma of the lung is preparing for discharge. When teaching the client about self-management with demeclocycline (Declomycin), the nurse should instruct the client to report which condition to the healthcare provider?
- A. Insomnia
- B. Muscle cramping
- C. Increased appetite
- D. Anxiety
Correct Answer: B
Rationale: The correct answer is B: Muscle cramping. SIADH causes dilutional hyponatremia due to increased ADH release. Demeclocycline is used to block the action of ADH. Muscle cramping can indicate electrolyte imbalances related to hyponatremia, which should be reported to the healthcare provider. Insomnia, increased appetite, and anxiety are not typically associated with the side effects or complications of demeclocycline or SIADH.
The nurse is assessing the thorax and lungs of a client who is experiencing respiratory difficulty. Which finding is most indicative of respiratory distress?
- A. Contractions of the sternocleidomastoid muscle.
- B. Respiratory rate of 20 breaths/min
- C. Downward movement of diaphragm with inspiration
- D. A pulse oximetry reading of SpO2 95%
Correct Answer: A
Rationale: The correct answer is A: Contractions of the sternocleidomastoid muscle. Contractions of the sternocleidomastoid muscle suggest that the client is using accessory muscles to breathe, which is a clear sign of respiratory distress. This finding indicates that the client is working harder to breathe, typically seen in conditions like asthma, COPD, or respiratory failure. Choices B, C, and D are not the most indicative of respiratory distress. A respiratory rate of 20 breaths/min falls within the normal range. Downward movement of the diaphragm with inspiration is a normal finding indicating effective diaphragmatic breathing. A pulse oximetry reading of SpO2 95% is within the normal range and does not necessarily indicate respiratory distress.
An adult male with schizophrenia who has been noncompliant in taking oral antipsychotic medications refuses a prescribed IM medication. What action should the nurse take?
- A. Notify the healthcare provider of the client's refusal
- B. Attempt to convince the client to take the medication
- C. Administer the medication without the client's consent
- D. Document the refusal and take no further action
Correct Answer: A
Rationale: The correct action is to notify the healthcare provider of the client's refusal. It is important for the healthcare provider to be informed so that they can decide on the next steps in the client's treatment, which may involve exploring alternative options or strategies. Attempting to convince the client to take the medication may not be effective, especially if the client is refusing. Administering the medication without the client's consent would violate the client's autonomy and rights. Simply documenting the refusal without further action may not address the client's treatment needs.
A school nurse is called to the soccer field because a child has a nosebleed (epistaxis). In what position should the nurse place the child?
- A. Sitting up and leaning forward
- B. Lying flat with legs elevated
- C. Lying on the side with the head slightly raised
- D. Sitting up and tilting the head back
Correct Answer: A
Rationale: The child with a nosebleed (epistaxis) should be placed in a sitting position, leaning forward, to prevent blood from flowing down the throat. This position helps to control the bleeding and prevents the child from swallowing blood, which can cause nausea or vomiting. Choice B is incorrect because elevating the legs is not recommended for nosebleeds. Choice C is incorrect because lying on the side with the head slightly raised is not the optimal position for managing a nosebleed. Choice D is incorrect because tilting the head back can lead to blood flowing down the throat and potentially cause aspiration.
The nurse is caring for a client with chronic kidney disease (CKD) who is receiving erythropoietin therapy. Which laboratory value should the nurse monitor closely?
- A. Serum potassium level
- B. Hemoglobin level
- C. White blood cell count
- D. Serum calcium level
Correct Answer: A
Rationale: The correct answer is A: Serum potassium level. When a client with chronic kidney disease (CKD) is receiving erythropoietin therapy, the nurse should closely monitor the serum potassium level. Erythropoietin therapy can stimulate red blood cell production, leading to an increased demand for potassium. This increases the risk of hyperkalemia, making it crucial to monitor potassium levels closely. Choices B, C, and D are incorrect because erythropoietin therapy primarily affects red blood cell production, not hemoglobin, white blood cell count, or serum calcium levels.