Nokea
A client is admitted to the hospital with recently diagnosed Type I diabetes mellitus and is to have fasting blood work drawn this morning. At 7:00 A.M., the lab has not arrived to draw the blood. The client's dose of regular insulin is scheduled for 7:30 A.M. What is the best action for the nurse to take?
- A. Give the insulin as ordered
- B. Withhold the insulin until the lab comes and the client will be eating within 15 to 30 minutes
- C. Withhold the insulin until the blood has been drawn and the client has eaten
- D. Do not administer insulin until the blood work has been drawn and the results have been called back to the unit
Correct Answer: C
Rationale: Withholding insulin until blood is drawn and the client has eaten prevents hypoglycemia during fasting blood work.
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The nurse at a freestanding health-care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy?
- A. Ask the client if he has somewhere he can go and live.
- B. Arrange for someone to give him insulin at a local homeless shelter.
- C. Notify Adult Protective Services about the client's situation.
- D. Ask the HCP to take the client off insulin because he is homeless.
Correct Answer: B
Rationale: Arranging insulin administration at a shelter ensures the client’s medical needs are met, advocating for his health. Housing questions, APS notification, and stopping insulin are less supportive.
The nurse is admitting a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which clinical manifestations should be reported to the health-care provider?
- A. Serum sodium of 112 mEq/L and a headache.
- B. Serum potassium of 5.0 mEq/L and a heightened awareness.
- C. Serum calcium of 10 mg/dL and tented tissue turgor.
- D. Serum magnesium of 1.2 mg/dL and large urinary output.
Correct Answer: A
Rationale: Severe hyponatremia (112 mEq/L) and headache in SIADH risk seizures, requiring immediate HCP notification. Other findings are less critical or unrelated.
Which finding would be the greatest cause for concern to the nurse during the early postoperative period following a thyroidectomy?
- A. Temperature of 100°F
- B. A sore throat
- C. Carpal spasm when the blood pressure is taken
- D. Complaints of pain in the area of the surgical incision
Correct Answer: C
Rationale: Carpal spasm (Trousseau’s sign) indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid gland injury.
The nurse is discussing ways to prevent diabetic ketoacidosis with the client diagnosed with type 1 diabetes. Which instruction is most important to discuss with the client?
- A. Refer the client to the American Diabetes Association.
- B. Do not take any over-the-counter (OTC) medications.
- C. Take the prescribed insulin even when unable to eat because of illness.
- D. Explain the need to get the annual flu and pneumonia vaccines.
Correct Answer: C
Rationale: Continuing insulin during illness prevents DKA by maintaining glucose control. ADA referral, avoiding OTC meds, and vaccines are secondary.
Preoperatively, which information is most important to teach the client before the subtotal thyroidectomy?
- A. Techniques for changing positions
- B. Reasons for performing leg exercises
- C. The necessity for daily dressing changes
- D. Postoperative use of the incentive spirometer
Correct Answer: D
Rationale: Using an incentive spirometer postoperatively helps prevent respiratory complications after thyroidectomy.