Nokea
A 26-year-old male client is brought by his wife to the emergency department (ED) unconscious. Blood is drawn for a stat blood count (CBC), fasting blood sugar level, and electrolytes. An indwelling urinary catheter is inserted. He has a history of type 1 diabetes (insulin-dependent diabetes mellitus [IDDM]). A diagnosis of ketoacidosis is made. Stat lab values reveal a blood sugar level of 520 mg/dL. Which of the following should the nurse expect to administer in the ER?
- A. D50W by IV push
- B. NPH insulin SC
- C. Regular insulin by IV infusion
- D. Sweetened grape juice by mouth
Correct Answer: C
Rationale: Regular insulin is the fastest acting-insulin; when given IV, it will immediately act to decrease blood sugar. Regular insulin is given to decrease blood glucose levels by promoting metabolism of glucose, inhibiting lipolysis and formation of ketone bodies.
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A male client is scheduled for a liver biopsy. In preparing him for this test, the nurse should:
- A. Explain that he will be kept NPO for 24 hours before the exam
- B. Practice with him so he will be able to hold his breath for 1 minute
- C. Explain that he will be receiving a laxative to prevent a distended bowel from applying pressure on the liver
- D. Explain that his vital signs will be checked frequently after the test
Correct Answer: D
Rationale: Post-liver biopsy, vital signs are monitored frequently to detect hemorrhage or shock, the most likely complications.
A 34-year-old client who is gravida 1, para 0 has a history of infertility and conceived this pregnancy while taking fertility drugs. She is at 32 weeks' gestation and is carrying triplets. She is complaining of low back pain and a feeling of pelvic pressure. Her cervical exam reveals a long, closed cervix. The nurse notes that the client is experiencing mild uterine contractions every 7-8 minutes after the nurse has placed her on the fetal monitor. Her condition should indicate that:
- A. Her cervix shows she will likely deliver soon
- B. The nurse should not be alarmed because mild uterine activity is common at 32 weeks' gestation
- C. She may be in preterm labor because this is more common with multiple pregnancies
- D. She most likely has a urinary tract infection (UTI) because this is common with pregnancy
Correct Answer: C
Rationale: Rhythmical contractions in conjunction with low back pain and pelvic pressure at 32 weeks in a woman carrying triplets are of great concern, indicating possible preterm labor, which is more common in multiple pregnancies.
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension,the nurse should:
- A. Place her in Trendelenburg position
- B. Decrease the rate of the IV infusion
- C. Administer oxygen via nasal cannula
- D. Increase the rate of the IV infusion
Correct Answer: D
Rationale: Hypotension from epidural anesthesia results from vasodilation. Increasing the IV infusion rate (e.g. with saline) restores blood volume and pressure. Trendelenburg may worsen spinal anesthesia spread and oxygen is secondary unless hypoxia occurs.
A client with a history of phenylketonuria (PKU) is seen in the local family planning clinic. While completing the intake history, the nurse provides information for a healthy pregnancy. Which statement indicates that the client needs further teaching?
- A. I can use artificial sweeteners to keep me from gaining too much weight when I get pregnant.
- B. I need to go back on a low-phenylalanine diet before I get pregnant.
- C. Fresh fruits and raw vegetables will make good between-meal snacks for me.
- D. My baby could be mentally retarded if I don't stick to a diet eliminating phenylalanine.
Correct Answer: A
Rationale: Artificial sweeteners like aspartame contain phenylalanine, which is harmful in PKU. A low-phenylalanine diet, healthy snacks, and preventing mental retardation are correct understandings.
A registered nurse is trying to determine the appropriate care that she should provide for her obstetrical clients. Which of the following documents is considered the legal standard of practice?
- A. State nursing practice act
- B. AWHONN Standards for the Nursing Care of Women and Newborns
- C. American Nurses' Association Standards of Maternal-Child Health Nursing
- D. International Council of Nurses' Code
Correct Answer: A
Rationale: The state nursing practice act determines the standard of care for the professional nurse. AWHONN Standards are published as recommendations and guidelines for maternal-newborn nursing. American Nurses' Association Standards are published as recommendations and guidelines for maternal-child health nursing. The International Council of Nurses' Code emphasizes the nurse's obligations to the client rather than to the physician. It is published as recommendations and guidelines by the international organization for professional nursing.