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A client tells the nurse that she has been working hard for the last 3 months to control her type 2 diabetes mellitus with diet and exercise. To determine the effectiveness of the client’s efforts, the nurse should check:
- A. Urine glucose level
- B. Serum fructosamine level
- C. Fasting blood glucose level
- D. Glycosylated hemoglobin level
Correct Answer: D
Rationale: The correct answer is D: Glycosylated hemoglobin level. This test provides an average blood glucose level over the past 2-3 months, reflecting long-term glycemic control. It is a more reliable indicator compared to other options. A: Urine glucose level only shows current glucose levels and is not a reliable indicator of long-term control. B: Serum fructosamine level reflects blood glucose control over the past 2-3 weeks, not the 3-month period the client has been making efforts. C: Fasting blood glucose level gives a snapshot of the current glucose level, not long-term control like glycosylated hemoglobin does.
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The patient database reveals that a patient has decreased oral intake, decreased oxygen saturation when ambulating, reports of shortness of breath when getting out of bed, and a productive cough. Which elements will the nurse identify as defining characteristics for the diagnostic label of Activity intolerance?
- A. Decreased oral intake and decreased oxygen saturation when ambulating NursingStoreRN Decreased oxygen saturation when ambulating and reports of shortness of breath
- B. when getting out of bed
- C. Reports of shortness of breath when getting out of bed and a productive cough
- D. Productive cough and decreased oral intake
Correct Answer: B
Rationale: Step 1: Activity intolerance is defined as insufficient physiological or psychological energy to endure or complete required or desired daily activities.
Step 2: In the scenario, the patient experiences shortness of breath when getting out of bed, indicating decreased ability to tolerate physical activity.
Step 3: This shortness of breath is a defining characteristic of activity intolerance as it reflects the patient's limited ability to perform activities of daily living.
Step 4: Other symptoms like decreased oral intake, decreased oxygen saturation, and productive cough may be related to other health issues but are not specific to activity intolerance.
Step 5: Therefore, choice B is the correct answer as it includes a key defining characteristic of activity intolerance, while other choices do not directly relate to the concept.
Which of the following is the medication of choice for anaphylaxis that the nurse should anticipate would be ordered?
- A. Epinephrine
- B. Digoxin (Lanoxin)
- C. Theophylline (Theo-Dur)
- D. Furosemide (Lasix)
Correct Answer: A
Rationale: The correct answer is A: Epinephrine. In anaphylaxis, epinephrine is the medication of choice due to its rapid onset of action and ability to reverse severe allergic reactions. It acts by constricting blood vessels, increasing heart rate, and opening airways. This helps counteract the dangerous drop in blood pressure and airway constriction seen in anaphylaxis. Digoxin, theophylline, and furosemide are not appropriate for anaphylaxis as they do not address the immediate life-threatening symptoms of anaphylaxis.
The nurse evaluates that furosemide IV is effective in treating pulmonary edema if which of the following patient signs or symptoms is resolved?
- A. Pedal edema
- B. Pink, frothy sputum
- C. Jugular vein distention
- D. Bradycardia
Correct Answer: B
Rationale: The correct answer is B: Pink, frothy sputum. This is because pink, frothy sputum is a classic sign of pulmonary edema, indicating fluid in the lungs. Furosemide IV is a diuretic that helps remove excess fluid from the body, including the lungs. Resolving pink, frothy sputum indicates that the treatment is effectively reducing the fluid in the lungs.
Incorrect choices:
A: Pedal edema - This refers to swelling in the feet and ankles, which is not directly related to pulmonary edema.
C: Jugular vein distention - This is a sign of heart failure, not specifically pulmonary edema.
D: Bradycardia - This is a slow heart rate and not a direct indicator of pulmonary edema resolution.
A client with suspected lymphoma is scheduled for lymphangiography. The nurse should inform the client that this procedure may cause which harmless, temporary change?
- A. Purplish stools
- B. Redness of the upper part of the feet
- C. Bluish urine
- D. Coldness of the soles
Correct Answer: C
Rationale: The correct answer is C: Bluish urine. During lymphangiography, a contrast dye is injected into the lymphatic vessels, which can be excreted through the urine, causing it to appear bluish temporarily. This change is harmless and resolves on its own.
Incorrect Answers:
A: Purplish stools - This is not a common side effect of lymphangiography.
B: Redness of the upper part of the feet - Redness is not typically associated with this procedure.
D: Coldness of the soles - Coldness is not a known temporary change resulting from lymphangiography.
Which blood product replaces missing clotting factors in the patient who has a bleeding disorder?
- A. Platelets
- B. Albumin
- C. Packed RBC
- D. Cryoprecipitate
Correct Answer: D
Rationale: The correct answer is D: Cryoprecipitate. Cryoprecipitate contains high levels of clotting factors such as fibrinogen, Factor VIII, Factor XIII, and von Willebrand factor, making it the ideal choice to replace missing clotting factors in patients with bleeding disorders. Platelets (A) help with clot formation but do not contain clotting factors. Albumin (B) is a protein used for volume replacement, not clotting factor replacement. Packed RBC (C) is used to increase oxygen-carrying capacity in anemic patients, not for clotting factor replacement.