Nokea
A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
- A. I will keep candy with me just in case my blood sugar drops.
- B. I need to stay out of the sun as much as possible.
- C. I often skip dinner because I don't feel hungry.
- D. I always wear my medical identification.
Correct Answer: C
Rationale: Skipping meals while on glyburide increases hypoglycemia risk, indicating a need for further teaching.
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The physician has ordered cultures for cytomegalovirus (CMV). Which statement is true of the collection of cultures for cytomegalovirus?
- A. Stool cultures are preferred for definitive diagnosis.
- B. Pregnant caregivers may obtain cultures.
- C. Collection of one specimen is sufficient.
- D. Accurate diagnosis depends on fresh specimens.
Correct Answer: D
Rationale: Fresh specimens are critical for accurate CMV culture results, as the virus is labile and degrades quickly.
A burn client's care plan reveals an expected outcome of no localized or systemic infection. Which assessment by the nurse supports this outcome?
- A. Wound culture results that show minimal bacteria
- B. Cloudy, foul-smelling urine output
- C. White blood cell count of 14,000
- D. Temperature of 101°F
Correct Answer: A
Rationale: Minimal bacteria in wound cultures supports the absence of localized infection, aligning with the care plan's goal.
The nurse is observing the respirations of a client when she notes that the respiratory cycle is marked by periods of apnea lasting from 10 seconds to 1 minute. The apnea is followed by respirations that gradually increase in depth and frequency. The nurse should document that the client is experiencing:
- A. Cheyne-Stokes respirations
- B. Kussmaul respirations
- C. Biot respirations
- D. Diaphragmatic respirations
Correct Answer: A
Rationale: Cheyne-Stokes respirations are characterized by periods of apnea followed by increasing depth and frequency of breaths.
A client with otosderosis is scheduled for a stapedectomy. Which finding suggests a complication involving the seventh cranial nerve?
- A. Diminished hearing
- B. Sensation of fullness in the ear
- C. Inability to move the tongue side to side
- D. Changes in facial sensation
Correct Answer: D
Rationale: The seventh cranial (facial) nerve controls facial movements and sensation; changes in facial sensation post-stapedectomy suggest nerve involvement.
The doctor has ordered antithrombolic stockings to be applied to the legs of the client with peripheral vascular disease. The nurse knows antithrombolic stockings should be applied:
- A. Before rising in the morning
- B. With the client in a standing position
- C. After bathing and applying powder
- D. Before retiring in the evening
Correct Answer: A
Rationale: Applying antithrombic stockings before rising prevents venous pooling, maximizing their effectiveness in improving circulation.