Nokea
The nurse in the outpatient clinic is caring for assigned clients with type 1 diabetes mellitus. Which client should the nurse recognize as having the highest risk of developing hypoglycemia?
- A. 29-year-old client with new-onset influenza
- B. 40-year-old client who is a cyclist and is training for an upcoming race
- C. 65-year-old client with cellulitis of the right leg
- D. 72-year-old client with emphysema who is receiving prednisone
Correct Answer: D
Rationale: Prednisone increases blood glucose, but abrupt cessation or dose changes can cause hypoglycemia in type 1 diabetes due to insulin sensitivity. Influenza, exercise, and cellulitis pose risks, but prednisone’s metabolic impact is greatest.
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The nurse in the outpatient clinic is caring for a 40-year-old client with acromegaly. Which of the following findings would be most important to report to the health care provider?
- A. Dark, leathery skin
- B. Fasting blood glucose level
- C. Presence of S3 and S4 heart sounds
- D. Reports of knee pain when walking
Correct Answer: C
Rationale: S3 and S4 heart sounds indicate heart failure, a serious complication of acromegaly due to cardiac hypertrophy, requiring urgent reporting. Skin changes, glucose levels, and knee pain are expected but less critical.
The nurse is reviewing new medication prescriptions for a client who has a suspected brain tumor. The client is scheduled for a CT scan of the head with IV iodinated contrast in 24 hours. The nurse should clarify the prescription for
- A. gabapentin
- B. amlodipine
- C. metformin
- D. phenytoin
Correct Answer: C
Rationale: Metformin should be held before and after iodinated contrast due to the risk of lactic acidosis if contrast-induced kidney injury occurs. Gabapentin, amlodipine, and phenytoin are safe with contrast.
During report, the nurse is given all of the following information. Which client should the nurse go to first?
- A. A diabetic has a blood sugar of 200.
- B. A client who had abdominal surgery earlier today is complaining of operative site pain.
- C. A client who had abdominal surgery yesterday has crackles on auscultation.
- D. A client who had a thyroidectomy earlier today is complaining of muscle spasms.
Correct Answer: D
Rationale: Muscle spasms post-thyroidectomy suggest hypocalcemia from parathyroid injury, a potentially life-threatening emergency requiring immediate assessment. High glucose, pain, or crackles are less urgent.
The nurse in the outpatient clinic is talking with a client who was diagnosed with hypertension 6 months ago. The client’s current blood pressure is 170/94 mm Hg. Which of the following questions would be most important for the nurse to ask?
- A. Are you feeling overwhelmed at home or work?
- B. Can you describe your daily eating habits to me?
- C. Do you smoke cigarettes or use tobacco products?
- D. How often do you take your antihypertensive medications?
Correct Answer: D
Rationale: Medication adherence is the most critical factor to assess in uncontrolled hypertension (170/94 mm Hg), as non-compliance is a common cause. Stress, diet, and smoking are secondary.
The nurse is preparing to suction a client who has a tracheostomy tube. Which of the following actions should the nurse take? Select all that apply.
- A. Administer 100% oxygen prior to suctioning the client
- B. Limit suctioning to 20 seconds during each suction pass
- C. Use sterile gloves and technique throughout the procedure
- D. Instill sterile normal saline into the tracheostomy tube prior to suctioning
- E. Apply suction while withdrawing the catheter from the tracheostomy tube
Correct Answer: A,C,E
Rationale: Pre-oxygenation, sterile technique, and suction on withdrawal prevent hypoxia and infection. Suctioning should be limited to 10-15 seconds, and saline instillation is not routinely recommended.