Nokea
A 7-year-old child with type 1 diabetes is admitted with diabetic ketoacidosis. Which intervention should the nurse prioritize?
- A. Administer insulin infusion
- B. Provide oral glucose
- C. Increase dietary carbohydrates
- D. Administer sodium bicarbonate
Correct Answer: A
Rationale: Insulin infusion is the priority in diabetic ketoacidosis to halt ketogenesis and correct hyperglycemia, addressing the underlying metabolic crisis.
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When performing an assessment on a mother who just delivered a healthy newborn, the nurse should expect to note that the fundus is positioned at which location?
- A. To the right of the abdomen
- B. At the level of the umbilicus
- C. Above the level of the umbilicus
- D. One fingerbreadth above the symphysis pubis
Correct Answer: B
Rationale: Immediately after delivery, the uterine fundus should be at the level of the umbilicus or one to three fingerbreadths below it and in the midline of the abdomen. A fundus that is not located in the midline may indicate a full bladder. If the fundus is above the umbilicus, this may indicate that blood clots in the uterus need to be expelled by fundal massage.
A client has an anaphylactic reaction to penicillin that results in respiratory distress. Which of the following medications should the nurse anticipate administering?
- A. Dopamine (Intropin).
- B. Epinephrine.
- C. Albuterol (Proventil).
- D. Diphenhydramine (Benadryl).
Correct Answer: B
Rationale: Epinephrine is the first-line treatment for anaphylaxis, as it rapidly reverses respiratory distress and other symptoms by constricting blood vessels and relaxing airways.
When a client has a tearing of tissue with irregular wound edges, the nurse should document this as:
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Colonization
Correct Answer: C
Rationale: A laceration is characterized by tearing of tissue with irregular wound edges. Contusions are bruises, abrasions are superficial, and colonization refers to bacterial presence, not wound type.
Which of the following is a nursing diagnosis that reflects some unexpected response to a therapy?
- A. Episiotomy extension related to a forceps delivery
- B. Respiratory depression related to NSAIDs
- C. Hemothorax related to a latex allergy
- D. All of the above
Correct Answer: D
Rationale: All listed diagnoses reflect unexpected responses to therapies (forceps delivery, NSAIDs, latex exposure), qualifying as adverse reactions.
A client being discharged from the hospital with a prescription for quinidine to control ventricular ectopy is provided medication instructions by the nurse. Which statement by the client would indicate the need for further teaching?
- A. The best time to schedule this medication is with my meals.
- B. I need to take this medication regularly, even if my heart feels strong.
- C. I should avoid alcohol, caffeine, and cigarettes while on this medication.
- D. If I get diarrhea, nausea, or vomiting, I need to stop the medication immediately.
Correct Answer: D
Rationale: Diarrhea, nausea, vomiting, loss of appetite, and dizziness are all common side effects of quinidine. If these should occur, the primary health care provider or nurse should be notified, but the medication should never be stopped by the client. A rapid decrease in the medication level of an antidysrhythmic could precipitate dysrhythmia. The remaining options are accurate client statements.