Nokea
A client received six units of regular insulin three hours ago.
- A. Which observation would be most concerning for a client who received six units of regular insulin three hours ago?
- B. Kussmaul respirations and diaphoresis.
- C. Anorexia and lethargy.
- D. Diaphoresis and trembling.
- E. Headache and polyuria.
Correct Answer: C
Rationale: Regular insulin peaks in 2-4 hours, and diaphoresis and trembling are classic signs of hypoglycemia, a potentially life-threatening complication requiring immediate intervention (e.g., administering skim milk). Kussmaul respirations indicate hyperglycemia, while anorexia, lethargy, headache, and polyuria are not specific to hypoglycemia.
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The nurse is caring for a 33-year-old woman after delivering an 8 lb 4 oz girl with talipes equinovarus. The woman confides to the nurse, 'I feel so bad that my baby is abnormal.' Which of the following responses by the nurse is BEST?
- A. It's understandable that you feel this way, but there are treatments to correct your baby's problem.
- B. Your baby is not really abnormal. Her feet just look different because of the way the muscles pull.
- C. You have nothing to feel guilty about. The abnormality is not your fault.
- D. Don't feel bad. You baby's abnormality can be corrected surgically.
Correct Answer: A
Rationale: accepts feelings and gives correct information, serial casting is used
The physician orders cholestyramine (Questran) 4 g PO qid for a 40-year-old client. The medication is provided in single-dose 4 g packets. The client asks the office nurse how to take the medication. The nurse should instruct the client to
- A. sprinkle the powder on a beverage, stir, and drink immediately.
- B. sprinkle the powder on food and eat slowly.
- C. add water to make a paste and eat, followed by 8 oz of water.
- D. sprinkle the powder on a beverage, let it stand a few minutes, and then stir and drink.
Correct Answer: D
Rationale: ensures uniform suspension
The home care nurse is performing an assessment of a client with pneumonia secondary to chronic pulmonary disease. Which of the following goals is MOST appropriate?
- A. Maintain and improve the quality of oxygenation.
- B. Improve the status of ventilation.
- C. Increase oxygenation of peripheral circulation.
- D. Correct the bicarbonate deficit.
Correct Answer: B
Rationale: to improve the quality of ventilation would refer to levels of carbon dioxide and oxygen
Which of the following strategies would be MOST therapeutic as the nurse tries to analyze a bulimic client's eating habits and the circumstances that precipitate the client's eating problems?
- A. Observe family communication patterns at a 'monitored mealtime.'
- B. Distract the client at mealtime.
- C. Assign the client a food/feelings/thoughts/actions journal.
- D. Assign the client to write a 'lifeline' in relation to eating behaviors.
Correct Answer: C
Rationale: implementation, nurse is trying to analyze and understand what triggers the client's binging and purging activities, so therapeutic nursing intervention of assigning a thought/feelings/actions (T/F/A) journal relating to client's eating behaviors will be most helpful to the nurse and therapeutic to the client; after this information is gained and reviewed, collaboration by the nurse and client on other strategies such as delay and distraction techniques, stress reduction, and developing a 'lifeline' in relation to eating behaviors will further benefit the client
The nurse is caring for a client with a new colostomy. Which of the following client statements indicates a need for further teaching?
- A. I will change the pouch when it is about one-third full.
- B. I will empty the pouch every evening before bed.
- C. I will avoid gas-forming foods like beans and broccoli.
- D. I will check the skin around the stoma for irritation.
Correct Answer: B
Rationale: the pouch should be emptied when one-third to one-half full, not on a fixed schedule