Nokea
A client diagnosed with diabetes mellitus receives 8 units of regular insulin subcutaneously at 7:30 am. The nurse should be most alert to signs of hypoglycemia at what time during the day?
- A. 9:30 am to 11:30 am
- B. 11:30 am to 1:30 pm
- C. 1:30 pm to 3:30 pm
- D. 3:30 pm to 5:30 pm
Correct Answer: A
Rationale: Regular insulin is a short-acting insulin. Its onset of action occurs in a half hour and peaks in 2 to 4 hours. Its duration of action is 4 to 6 hours. A hypoglycemic reaction will most likely occur at peak time, which in this situation is between 9:30 am and 11:30 am.
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A client has not ingested any food or liquids for 4 hours after two episodes of nausea and vomiting. What will the nurse offer the client initially now that she or he is no longer nauseated?
- A. Toast
- B. Gelatin
- C. Dry cereal
- D. Ginger ale
Correct Answer: D
Rationale: Clear liquids are best tolerated first after episodes of nausea and vomiting. If the client tolerates sips (20 to 30 mL at a time) of clear liquids, such as water or ginger ale (with the carbonation removed if better tolerated), then the amounts may be increased and gelatin, tea, and broth may be added. Once these are tolerated, solid foods such as toast, cereal, chicken, and other easily digested foods may be tried.
The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed?
- A. Dextran
- B. 0.9% normal saline
- C. 5% dextrose in water
- D. 5% dextrose in 0.9% normal saline
Correct Answer: B
Rationale: Normal saline 0.9% is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is usually sufficient. Additionally, Dextran has potential adverse effects. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from hemorrhage or burns.
A client diagnosed with diabetes mellitus is at 36 weeks' gestation. The client has had weekly reactive nonstress tests for the last 3 weeks. This week, the nonstress test was nonreactive after 40 minutes. Based on these results, the nurse should prepare the client for which intervention?
- A. A contraction stress test
- B. Immediate induction of labor
- C. Hospitalization with continuous fetal monitoring
- D. A return appointment in 2 days to repeat the nonstress test
Correct Answer: A
Rationale: A nonreactive nonstress test after 40 minutes indicates that the fetus did not show the expected heart rate accelerations, which may suggest fetal compromise, particularly in a high-risk pregnancy such as one with diabetes mellitus. The next step is typically a contraction stress test to further assess fetal well-being by evaluating the fetal heart rate response to uterine contractions. Immediate induction or hospitalization may be premature without further evaluation, and repeating the nonstress test in 2 days delays necessary assessment.
The emergency department nurse is assessing a client who abruptly discontinued benzodiazepine therapy and is experiencing withdrawal. Which manifestations of withdrawal should the nurse expect to note? Select all that apply.
- A. Tremors
- B. Sweating
- C. Lethargy
- D. Agitation
- E. Nervousness
- F. Muscle weakness
Correct Answer: A,B,D,E
Rationale: Benzodiazepines should not be abruptly discontinued because withdrawal symptoms are likely to occur. Withdrawal symptoms include tremor, sweating, agitation, nervousness, insomnia, anorexia, and muscular cramps. Withdrawal symptoms from long-term, high-dose benzodiazepine therapy include paranoia, delirium, panic, hypertension, and status epilepticus. Lethargy is not associated with benzodiazepine withdrawal.
The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety?
- A. Monitoring for heel breakdown
- B. Monitoring for bladder distention
- C. Monitoring for extremity shortening
- D. Monitoring for blanching ability of toe nail beds
Correct Answer: D
Rationale: With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although heel breakdown, bladder distention, or extremity lengthening or shortening can occur, these complications are not potentially life-threatening complications.