Nokea
A client who has Type 1 diabetes mellitus is admitted for alcohol detoxification. A moderate sliding scale for insulin is ordered. How often should the nurse expect to take glucose levels?
- A. Every time medication is administered
- B. When the client is symptomatic
- C. Before meals and at bedtime
- D. Every two hours
Correct Answer: C
Rationale: Sliding scale insulin for Type 1 diabetes requires glucose checks before meals and at bedtime to adjust dosing, ensuring glycemic control.
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The nurse is caring for a client with liver cirrhosis. Which of the following assessment findings would warrant immediate follow up?
- A. Black, tarry stool
- B. Bright red-streaked stool
- C. Light gray clay-colored stool
- D. Small, dry, rocky stool
Correct Answer: A
Rationale: Black, tarry stool (melena) indicates upper gastrointestinal bleeding, a serious complication in cirrhosis due to portal hypertension or varices, requiring immediate intervention.
A client with a below-the-knee amputation is experiencing phantom limb pain. Which action by the nurse would be most effective in relieving the pain?
- A. Acknowledging the presence of the pain
- B. Elevating the stump on a pillow
- C. Applying a transcutaneous nerve stimulator unit (TENS)
- D. Rewrapping the stump
Correct Answer: C
Rationale: Applying a TENS unit can help relieve phantom limb pain by stimulating nerves and reducing pain signals. Acknowledging the pain is supportive but does not directly relieve it. Elevating the stump may help with swelling but not specifically phantom pain. Rewrapping the stump may provide comfort but is less effective than TENS for pain relief.
During the admission bath, the nurse notes a region of impaired skin under a large sacral dressing. Which of the following actions by the nurse are appropriate? Select all that apply.
- A. Discusses the client's need for a nutrient-rich, high-calorie diet with the dietician
- B. Documents the impaired skin as an unstageable pressure injury in the client's medical record
- C. Gently cleanses the impaired skin with normal saline and pats the area dry with gauze
- D. Places a hydrophilic dressing over the impaired skin after performing wound care
- E. Repositions the client frequently and avoids putting pressure on the impaired skin
Correct Answer: A,C,D,E
Rationale: A nutrient-rich diet (A) supports wound healing. Cleansing with saline (C) prevents infection. A hydrophilic dressing (D) promotes a moist healing environment. Frequent repositioning (E) reduces pressure on the impaired skin.
The nurse is collecting data from a client with heart failure. The nurse notes that the client is agitated, has crackles bilaterally, and is reporting dyspnea and anxiety. The nurse should place the client in
- A. modified Trendelenburg position
- B. high Fowler position
- C. left Sims position
- D. supine position
Correct Answer: B
Rationale: High Fowler position optimizes lung expansion and reduces preload, alleviating dyspnea and crackles in acute heart failure exacerbation.
The nurse is reinforcing teaching for a client who has a new prescription for levothyroxine. Which of the following information should the nurse reinforce?
- A. Discontinue the medication if you become pregnant.
- B. Take the medication at bedtime to decrease drowsiness.
- C. Notify your health care provider if you experience palpitations.
- D. Take the medication with a snack if you experience an upset stomach.
Correct Answer: C
Rationale: Palpitations may indicate levothyroxine overdose or hyperthyroidism, requiring prompt reporting to adjust the dose or evaluate thyroid function.