Nokea
A 27-year-old man was diagnosed with type I diabetes 3 months ago. Two weeks ago he complained of pain, redness, and tenderness in his right lower leg. He is admitted to the hospital with a slight elevation of temperature and vague complaints of 'not feeling well.' At 4:30 PM on the day of his admission, his blood glucose level is 50 mg; dinner will be served at 5:00 PM. The best nursing action would be to:
- A. Give him 3 tbsp of sugar dissolved in 4 oz of grape juice to drink
- B. Ask him to dissolve three pieces of hard candy in his mouth
- C. Have him drink 4 oz of orange juice
- D. Monitor him closely until dinner arrives
Correct Answer: C
Rationale: Four ounces of orange juice will raise blood sugar to a normal level and sustain it until dinner, preventing hypoglycemia. The other options either raise blood sugar too high or are insufficient.
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A client with a history of alcoholism is admitted with a diagnosis of cirrhosis. The nurse can expect the client to exhibit:
- A. Lower extremity edema
- B. Dilated pupils
- C. Warm, dry skin
- D. Bradycardia
Correct Answer: A
Rationale: Cirrhosis impairs liver function, leading to portal hypertension and hypoalbuminemia, causing lower extremity edema. Dilated pupils, warm skin, and bradycardia are not typical.
A client is to be discharged from the hospital and is to continue taking warfarin 2.5 mg po bid. Which of the following should be included in her discharge teaching concerning the warfarin therapy?
- A. If you forget to take your morning dose, double the night time dose.'
- B. You should take aspirin instead of acetaminophen (Tylenol) for headaches.'
- C. Carry a medications alert card with you at all times.'
- D. You should use a straight-edge razor when shaving your arms and legs.'
Correct Answer: C
Rationale: Warfarin must always be taken exactly as directed. Clients should be instructed never to skip or double up on their dosage. Aspirin decreases platelet aggregation, which would potentiate the effects of the coumadin. Healthcare providers need to be aware of persons on warfarin therapy prior to the initiation of any diagnostic tests and/or surgery to help prevent bleeding complications. An electric razor should be used to prevent accidental cutting, which can lead to bleeding.
The client is prescribed ipratropium (Atrovent) and albuterol (Proventil) via inhaler. Which instruction should the nurse include?
- A. Use albuterol first, then ipratropium.'
- B. Use ipratropium first, then albuterol.'
- C. Use both inhalers simultaneously.'
- D. Use only one inhaler per day.'
Correct Answer: A
Rationale: Albuterol, a bronchodilator, is used first to open airways, followed by ipratropium, an anticholinergic, to maintain bronchodilation. Simultaneous or single daily use is incorrect.
Which of the following would differentiate acute from chronic respiratory acidosis in the assessment of the trauma client?
- A. Increased PaCO2
- B. Decreased PaO2
- C. Increased HCO3
- D. Decreased base excess
Correct Answer: C
Rationale: Increased PaCO2 is present in both acute and chronic respiratory acidosis due to hypoventilation. Decreased PaO2 may occur in respiratory acidosis but does not differentiate acute from chronic. Increased HCO3 indicates renal compensation, which occurs in chronic respiratory acidosis as the body attempts to buffer the excess CO2, but not in acute cases where compensation has not yet occurred. Decreased base excess is not specific to differentiating acute from chronic respiratory acidosis.
A female client is exhibiting signs of respiratory distress. Which of the following signs indicate a possible pneumothorax?
- A. Crackles or rales on the affected side
- B. Bradypnea and bradycardia
- C. Shortness of breath and sharp pain on the affected side
- D. Increased breath sounds on the affected side
Correct Answer: C
Rationale: With a pneumothorax, air occupies the pleural space. Crackles or rales are heard with increased fluid or secretions and would not be present with air in the space. With a pneumothorax, the client would experience tachypnea and tachycardia to compensate for the decrease in oxygenation. Symptoms of pneumothorax include shortness of breath, sharp pain on the affected side with movement or coughing, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. With a pneumothorax, breath sounds would be decreased on the affected side (indicates air in the pleural space).