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A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which laboratory finding is most indicative of this condition?
- A. Serum glucose of 180 mg/dL
- B. Blood pH of 7.30
- C. Positive urine ketones
- D. Serum bicarbonate of 25 mEq/L
Correct Answer: C
Rationale: The correct answer is C: Positive urine ketones. In diabetic ketoacidosis (DKA), the body breaks down fat for energy due to a lack of insulin, leading to ketone production. Positive urine ketones are a hallmark laboratory finding in DKA as they directly reflect the presence of ketosis. Choice A, serum glucose of 180 mg/dL, may be elevated in DKA, but it is not specific to this condition. Choice B, blood pH of 7.30, often shows acidosis in DKA, but urine ketones are more specific to the presence of ketosis. Choice D, serum bicarbonate of 25 mEq/L, would typically be low in DKA due to acidosis rather than elevated.
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A client is scheduled for an abdominal ultrasound in the morning and has been instructed to fast overnight. The client asks the nurse why fasting is necessary. What is the best response?
- A. It helps reduce the production of intestinal gases.
- B. It ensures clearer imaging by emptying the stomach.
- C. It prevents the risk of aspiration during the procedure.
- D. It is a standard procedure for all surgical interventions.
Correct Answer: B
Rationale: The correct answer is B: 'It ensures clearer imaging by emptying the stomach.' Fasting before an abdominal ultrasound is essential to empty the stomach, allowing for better visualization of the abdominal organs. This improves the quality of the imaging and enhances diagnostic accuracy. Choices A, C, and D are incorrect because reducing intestinal gases, preventing aspiration, and being a standard procedure for surgical interventions are not the primary reasons for fasting before an abdominal ultrasound.
A client with a diagnosis of depression is prescribed an SSRI. What is the most important information the nurse should provide?
- A. Take the medication as prescribed.
- B. Avoid consuming grapefruit juice.
- C. Report any thoughts of self-harm immediately.
- D. Understand that improvement may take weeks.
Correct Answer: C
Rationale: The most important information the nurse should provide to a client prescribed an SSRI for depression is to report any thoughts of self-harm immediately. SSRIs can increase suicidal ideation, especially at the beginning of treatment, so it is crucial to monitor for this and take appropriate actions. While it is important to take the medication as prescribed (Choice A), the immediate need for reporting self-harm ideation takes precedence. Avoiding grapefruit juice (Choice B) is a general precaution with certain medications but not as critical in this scenario. Understanding that improvement may take weeks (Choice D) is important for managing treatment expectations, but ensuring the client's safety in the context of suicidal ideation is the top priority.
The unlicensed assistive personnel (UAP) reports to the nurse that a client refused to bathe for the third consecutive day. What action is best for the nurse to take?
- A. Ask the client why the bath was refused
- B. Ask family members to encourage the client to bathe
- C. Explain the importance of good hygiene to the client
- D. Reschedule the bath for the following day
Correct Answer: A
Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reasons for refusal can guide appropriate interventions, respecting client autonomy while addressing any underlying issues. Choice B is not the best course of action as involving family members may not address the client's specific concerns. Choice C, while important, may not directly address the immediate refusal to bathe. Choice D does not address the underlying reasons for the refusal and may not lead to a resolution.
A client is admitted to the hospital with second and third degree burns to the face and neck. How should the nurse best position the client to maximize function of the neck and face and prevent contracture?
- A. The neck extended backward using a rolled towel behind the neck
- B. Prone position using pillows to support both arms outward from the torso
- C. Side-lying position using pillows to support the abdomen and back
- D. The neck forward using pillows under the head and sandbags on both sides
Correct Answer: D
Rationale: After sustaining burns to the face and neck, positioning is crucial to maintain functional posture, reduce pain, and prevent contractures. Placing the neck forward using pillows under the head and sandbags on both sides is the best option in this scenario. This position helps prevent neck and facial contractures, allowing for optimal function and healing. Choices A, B, and C do not adequately address the specific needs of a client with burns to the face and neck. Choice A could potentially exacerbate neck contractures, Choice B focuses on arm support rather than neck and face positioning, and Choice C does not directly address the needs of the burned face and neck, making them less effective in preventing contractures in these critical areas.
A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulant therapy. Which instruction should the nurse provide to the client?
- A. Avoid walking as much as possible
- B. Report any signs of bleeding to the healthcare provider
- C. Take aspirin for additional pain relief
- D. Wear compression stockings at night
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.