Nokea
An older client with long-term type 2 diabetes Mellitus (DM) is seen in the clinic for a routine health assessment. Which assessment would the nurse complete to determine if a patient with type 2 diabetes Mellitus (DM) is experiencing long-term complications?
- A. Signs of respiratory tract infection
- B. Sensation in feet and legs
- C. Skin condition of lower extremities
- D. Serum creatinine and blood urea nitrogen (BUN)
Correct Answer: B
Rationale: Assessing sensation in the feet and legs is crucial for detecting diabetic neuropathy, a common long-term complication of diabetes. While signs of respiratory tract infection, skin condition of lower extremities, and serum creatinine and blood urea nitrogen levels are important assessments in diabetic care, they are not specific for detecting long-term complications like neuropathy.
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The client with chronic renal failure is receiving education on managing fluid intake. Which of the following statements by the client indicates a need for further teaching?
- A. I can drink as much water as I want.
- B. I should increase my intake of high-sodium foods.
- C. I can skip a dialysis session if I feel tired.
- D. I can eat whatever I want as long as I take my medications.
Correct Answer: C
Rationale: Choice C is the correct answer. Clients with chronic renal failure should not skip dialysis sessions, as this can lead to serious complications. Dialysis is crucial for managing fluid and electrolyte balance in these clients. Choice A is incorrect because clients with renal failure often have fluid restrictions. Choice B is incorrect as high-sodium foods can worsen fluid retention in clients with renal failure. Choice D is incorrect because dietary restrictions are important in managing chronic renal failure, and eating whatever one wants can lead to further complications.
What is an expected outcome when a client is receiving an IV administration of furosemide?
- A. Increased blood pressure.
- B. Increased urine output.
- C. Decreased pain.
- D. Decreased premature ventricular contractions.
Correct Answer: B
Rationale: The correct answer is B: Increased urine output. Furosemide is a loop diuretic that works by inhibiting the reabsorption of sodium and chloride in the ascending loop of Henle in the kidneys, leading to increased urine production. This diuretic effect helps to reduce fluid volume in the body, making it an expected outcome when a client is receiving furosemide. Choice A, increased blood pressure, is incorrect because furosemide typically causes a decrease in blood pressure due to its diuretic effect. Choice C, decreased pain, and choice D, decreased premature ventricular contractions, are unrelated to the pharmacological action of furosemide.
Which of the following symptoms would a healthcare provider expect to find in a patient with hyperkalemia?
- A. Muscle cramps.
- B. Hypertension.
- C. Bradycardia.
- D. Tachycardia.
Correct Answer: D
Rationale: Tachycardia is the correct symptom to expect in a patient with hyperkalemia. Hyperkalemia, or high potassium levels in the blood, can affect the electrical activity of the heart. Increased potassium levels can lead to changes in the heart's rhythm, potentially causing tachycardia (rapid heart rate) or other cardiac arrhythmias. Muscle cramps (choice A) are not typically associated with hyperkalemia. Hypertension (choice B) is not a common symptom of hyperkalemia; in fact, high potassium levels can sometimes cause low blood pressure. Bradycardia (choice C), or a slow heart rate, is usually not a primary symptom of hyperkalemia; instead, hyperkalemia tends to be associated with faster heart rates or arrhythmias.
A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat:
- A. Within 10 to 15 minutes after the injection.
- B. 1 hour after the injection.
- C. At any time, because timing of meals with lispro injections is unnecessary.
- D. 2 hours before the injection.
Correct Answer: A
Rationale: The correct answer is to eat within 10 to 15 minutes after the injection. Insulin lispro, also known as Humalog, is a rapid-acting insulin that starts working very quickly. Eating shortly after the injection helps match the food intake with the insulin action, reducing the risk of hypoglycemia. Choice B is incorrect because waiting 1 hour after the injection may lead to a mismatch between insulin activity and food intake. Choice C is incorrect as timing meals with lispro injections is essential to optimize glycemic control. Choice D is incorrect as eating 2 hours before the injection is not in alignment with the rapid action of insulin lispro and may lead to fluctuations in blood sugar levels.
Four days following an abdominal aortic aneurysm repair, the client is exhibiting edema of both lower extremities, and pedal pulses are not palpable. Which action should the nurse implement first?
- A. Elevate extremities on pillows
- B. Evaluate edema for pitting
- C. Assess pulses with a vascular Doppler
- D. Wrap the feet with warmed blankets
Correct Answer: C
Rationale: In this scenario, the priority action for the nurse is to assess pulses with a vascular Doppler. The absence of palpable pedal pulses following an abdominal aortic aneurysm repair raises concerns about compromised blood flow, which could lead to serious complications like ischemia or thrombosis. Evaluating and confirming the presence or absence of pulses is crucial to guide further interventions. Elevating extremities on pillows (Choice A) may be beneficial for managing edema, but it is not the immediate priority when pulses are not palpable. Evaluating edema for pitting (Choice B) can provide additional information about fluid status but does not address the primary concern of absent pulses. Wrapping the feet with warmed blankets (Choice D) is not appropriate in this situation and may not address the underlying vascular issue.