Nokea
A client has type1 diabetes. Her husband finds her unconscious at home and administers glucagons, 0.5 mg S.C. She awakens in 5 minutes .Why her husband offer a complex carbohydrate snack to her as soon as possible?
- A. To decrease the possibility of nausea and vomiting
- B. To restore liver glycogen and prevent secondary hypoglycemia
- C. To stimulate her appetite
- D. To decrease the amount of glycogen in her system
Correct Answer: B
Rationale: The correct answer is B. After administering glucagon for hypoglycemia, the body may deplete its glycogen stores from the liver. Offering a complex carbohydrate snack will help restore liver glycogen, preventing secondary hypoglycemia. This is crucial for maintaining blood glucose levels in individuals with type 1 diabetes. Choices A, C, and D are incorrect because offering a complex carbohydrate snack is primarily aimed at restoring liver glycogen to prevent further hypoglycemic episodes, not to address nausea/vomiting, stimulate appetite, or decrease glycogen levels.
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For a client diagnosed with idiopathic thrombocytopenic purpura (ITP), which nursing intervention is appropriate?
- A. Teaching coughing and deep-breathing techniques to help prevent infection
- B. Administering platelets, as ordered to maintain an adequate platelet count
- C. Giving aspirin, as prescribed to control body temperature
- D. Administering stool softeners, as ordered, to prevent straining during infection
Correct Answer: B
Rationale: The correct answer is B: Administering platelets, as ordered to maintain an adequate platelet count. In ITP, the client has low platelet count leading to risk of bleeding. Administering platelets helps raise platelet levels and prevent bleeding complications. Teaching coughing and deep-breathing techniques (A) is important for preventing respiratory infections but not directly related to ITP. Giving aspirin (C) is contraindicated as it can further decrease platelet count. Administering stool softeners (D) is important for preventing straining but not specific to managing ITP.
A client with a history of cardiac dysrhythmias is admitted to the hospital with the diagnosis of dehydration. The nurse should anticipate that the physician will order;
- A. A glass of water every hour until hydrated
- B. Small frequent intake of juices, broth, or milk
- C. Short-term NG replacement of fluids and nutrients
- D. A rapid IV infusion of an electrolyte and glucose solution
Correct Answer: B
Rationale: Step-by-step rationale for choice B being correct:
1. Dehydration leads to electrolyte imbalances, which can exacerbate cardiac dysrhythmias.
2. Small frequent intake of fluids like juices, broth, or milk helps in gradual rehydration without overwhelming the cardiovascular system.
3. This approach allows for better absorption of fluids and nutrients, promoting hydration without causing sudden shifts in electrolyte levels.
Summary of why other choices are incorrect:
A: Just drinking a glass of water every hour may not address electrolyte imbalances or provide adequate hydration for a client with cardiac dysrhythmias.
C: NG replacement may not be necessary if the client can tolerate oral intake, and it is more invasive than needed.
D: A rapid IV infusion may lead to sudden changes in electrolyte levels, potentially worsening the dysrhythmias.
Deaths have occurred when potassium chloride has been used incorrectly to flush a lock or central venous catheter. Which of the ff precautions should a nurse take to minimize this risk?
- A. Use a dilute form of potassium chloride before flushing locks
- B. Warm the KCL before flushing locks
- C. Read labels carefully on vials containing flush solutions for locks
- D. Replace the existing locks with new ones to avoid flushing
Correct Answer: C
Rationale: Step 1: Reading labels carefully on vials containing flush solutions for locks is crucial to ensure the correct solution is being used.
Step 2: Potassium chloride should not be used to flush locks as it can be fatal if administered incorrectly.
Step 3: By carefully reading labels, the nurse can verify that the correct solution is being used, thus minimizing the risk of using potassium chloride.
Summary:
- Choice A is incorrect as using a dilute form of potassium chloride does not address the issue of incorrect administration.
- Choice B is incorrect as warming the solution does not prevent the risk associated with using potassium chloride.
- Choice D is incorrect as replacing locks does not address the root cause of the issue, which is improper administration.
The nurse is caring for a client with thrombocytopenia. What is the best way to protect this client?
- A. Limit visits by family members
- B. Encourage the client to use a wheelchair
- C. Use the smallest needle possible for injections
- D. Maintain accurate fluid intake and output records
Correct Answer: C
Rationale: The correct answer is C: Use the smallest needle possible for injections. This is important for a client with thrombocytopenia because they have a low platelet count, leading to an increased risk of bleeding. Using a small needle minimizes the risk of causing bleeding or bruising during injections. Limiting family visits (choice A) is not directly related to protecting the client from bleeding. Encouraging wheelchair use (choice B) is not specifically relevant to protecting the client with thrombocytopenia. Maintaining accurate fluid intake and output records (choice D) is important but not directly related to preventing bleeding in a client with thrombocytopenia.
A charge nurse is evaluating a new nurse’s plan of care. Which finding will cause the charge nurse to follow up? Assigning a documented nursing diagnosis of Risk for infection for a patient on
- A. intravenous (IV) antibiotics
- B. Completing an interview and physical examination before adding a nursing diagnosis
- C. Developing nursing diagnoses before completing the database
- D. Including cultural and religious preferences in the database
Correct Answer: C
Rationale: The correct answer is C: Developing nursing diagnoses before completing the database. This is incorrect because developing nursing diagnoses should be based on a comprehensive assessment and analysis of the patient's data. By developing nursing diagnoses before completing the database, the new nurse may overlook important information that could impact the accuracy of the diagnosis and subsequent care plan.
Choice A (intravenous antibiotics) is incorrect because assigning a nursing diagnosis of Risk for infection for a patient on IV antibiotics is a common and appropriate practice given the increased risk of infection associated with invasive procedures.
Choice B (Completing an interview and physical examination before adding a nursing diagnosis) is incorrect because nursing diagnoses should be developed based on the data collected during the assessment process, which includes the interview and physical examination. It is not necessary to complete the entire assessment before assigning a nursing diagnosis.
Choice D (Including cultural and religious preferences in the database) is incorrect because while it is important to consider cultural and religious preferences in care planning, this does not directly relate to the