Nokea
A 10-year-old child has the following blood glucose readings during a 24-hour period. Which reading requires the most immediate intervention?
- A. 50 mg/dL.
- B. 100 mg/dL.
- C. 150 mg/dL.
- D. 200 mg/dL.
Correct Answer: A
Rationale: A blood glucose of 50 mg/dL indicates hypoglycemia, requiring immediate intervention to prevent neurological complications.
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The nurse is caring for a client with a history of osteoarthritis. Which of the following non-pharmacologic interventions should be included in the plan of care?
- A. Apply heat to affected joints.
- B. Restrict weight-bearing activities.
- C. Encourage a low-protein diet.
- D. Limit range-of-motion exercises.
Correct Answer: A
Rationale: Heat therapy reduces stiffness and pain in osteoarthritis.
The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include:
- A. Kussmaul's respirations
- B. Excessive hunger
- C. Dry, flaky skin
- D. High blood pressure
Correct Answer: A
Rationale: Kussmaul's respirations (rapid, deep breathing) are a hallmark of diabetic ketoacidosis as the body compensates for acidosis. Excessive hunger is more typical of hypoglycemia, and dry skin or hypertension are less specific.
The nurse is teaching a client with a new diagnosis of celiac disease about dietary management. Which of the following foods should the client avoid?
- A. Rice.
- B. Wheat.
- C. Corn.
- D. Potatoes.
Correct Answer: B
Rationale: Wheat contains gluten, which must be avoided in celiac disease.
A client in the second stage of labor has had no anesthesia or analgesia. The nurse should assist the client into which of the following positions so the client can begin pushing?
- A. Squatting with the body curved in a C shape.
- B. Side-lying while keeping the head elevated.
- C. In the knee-chest position while keeping the head lowered.
- D. Squatting with the back arched.
Correct Answer: A
Rationale: Squatting with a C-shaped body facilitates pushing by aligning the pelvis and using gravity, ideal for the second stage of labor without anesthesia.
A client with a history of type 1 diabetes is prescribed insulin aspart (NovoLog). The nurse should instruct the client to:
- A. Take the insulin 5–10 minutes before meals.
- B. Mix the insulin with long-acting insulin.
- C. Take the insulin at bedtime.
- D. Stop the insulin if blood glucose normalizes.
Correct Answer: A
Rationale: Insulin aspart, a rapid-acting insulin, is taken 5–10 minutes before meals for prandial coverage.