Nokea
The nurse is planning to complete noon assessments for four assigned clients with type 1 DM. All of the clients received subcutaneous insulin aspart at 0800 hours. Place the clients in the order of priority for the nurse's assessment.
- A. The 60-year-old client who is nauseated and has just vomited for the second time
- B. The 45-year-old client who is dyspneic and has chest pressure and new-onset atrial fibrillation
- C. The 75-year-old client with a fingerstick blood glucose level of 300 mg/dL
- D. The 50-year-old client with a fingerstick blood glucose level of 70 mg/dL
Correct Answer: B,A,C,D
Rationale: The 45-year-old client with dyspnea, chest pressure, and atrial fibrillation is at risk for a cardiac event, requiring immediate assessment. The 60-year-old with vomiting is next due to potential hypoglycemia. The 75-year-old with hyperglycemia needs attention but is less urgent. The 50-year-old with normal glucose is last.
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An adult is admitted to the hospital with a diagnosis of hypothyroidism. Which findings would the nurse most likely elicit during the nursing assessment?
- A. Elevated blood pressure and temperature
- B. Tachycardia and weight gain
- C. Hypothermia and constipation
- D. Moist skin and coarse hair
Correct Answer: C
Rationale: Hypothyroidism causes hypothermia and constipation due to slowed metabolism, unlike the other symptoms.
Which of the following provides the best evidence that the dietary measures to control functional hypoglycemia are therapeutic?
- A. The client experiences fewer incidences of weakness and tremors.
- B. The client experiences fewer incidences of thirst and dry mouth.
- C. The client experiences fewer incidences of muscle spasms and fatigue.
- D. The client experiences fewer incidences of hunger and abdominal cramps.
Correct Answer: A
Rationale: Reduced weakness and tremors indicate stabilized blood glucose levels in functional hypoglycemia.
To prepare for potential postoperative complications related to the thyroidectomy, which item is necessary to keep at the client's bedside?
- A. Dressing change kit
- B. Tracheostomy tray
- C. Ampule of epinephrine
- D. Mechanical ventilator
Correct Answer: B
Rationale: A tracheostomy tray is essential in case of airway obstruction due to swelling or hematoma post-thyroidectomy.
Before administering this medication, what is essential for the nurse to ask the client?
- A. Do you have trouble swallowing?
- B. Do you keep the child form of medication?
- C. Have you had digestive disorders in the past?
- D. Is there a possibility you could be pregnant?
Correct Answer: D
Rationale: Propylthiouracil is contraindicated in pregnancy due to potential teratogenic effects.
Which information is most important for the nurse to elicit from the client to effectively evaluate compliance with the prescribed therapy?
- A. The dosage and frequency of insulin administration
- B. The client's glucose monitoring records for the past week
- C. The client's weight and vital signs before the office interview
- D. The symptoms experienced in the past month
Correct Answer: B
Rationale: Glucose monitoring records provide direct evidence of blood glucose control and therapy compliance.