Nokea
A client with a diagnosis of diabetes mellitus has a blood glucose level of 644 mg/dL (36.8 mmol/L). The nurse interprets that this client is at risk of developing which type of acid-base imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: Diabetes mellitus can lead to metabolic acidosis. When the body does not have sufficient circulating insulin, the blood glucose level rises. At the same time, the cells of the body use all available glucose. The body then breaks down glycogen and fat for fuel. The by-products of fat metabolism are acidotic and can lead to the condition known as diabetic ketoacidosis. Options 2, 3, and 4 are incorrect.
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The nurse caring for a postpartum client should suspect that the client is experiencing endometritis if which is noted?
- A. Breast engorgement
- B. Elevated white blood cell count
- C. Lochia rubra on the second day postpartum
- D. Fever over 38°C (100.4°F), beginning 2 days postpartum
Correct Answer: D
Rationale: Endometritis is a common cause of postpartum infection. The presence of fever of 38°C (100.4°F) or more on 2 successive days of the first 10 postpartum days (not counting the first 24 hours after birth) is indicative of a postpartum infection. Breast engorgement is a normal response in the postpartum period and is not associated with endometritis. The white blood cell count of a postpartum woman is normally elevated; thus, this method of detecting infection is not of great value in the puerperium. Lochia rubra on the second day postpartum is a normal finding.
A client is resuming a diet after a Billroth II procedure. To minimize complications associated with eating, which actions should the nurse teach the client? Select all that apply.
- A. Laying down after eating
- B. Eating a diet high in protein
- C. Drinking liquids with meals
- D. Eating six small meals per day
- E. Eating concentrated sweets only between meals
Correct Answer: A,B,D
Rationale: The client who has had a Billroth II procedure is at risk for dumping syndrome. The client should lie down after eating and avoid drinking liquids with meals to prevent this syndrome. The client should be placed on a dry diet that is high in protein, moderate in fat, and low in carbohydrates. Frequent small meals are encouraged, and the client should avoid concentrated sweets.
On assessment of a newborn being admitted to the nursery, the nurse palpates the anterior fontanel and notes that it feels soft. The nurse determines that this finding indicates which condition?
- A. Dehydration
- B. A normal finding
- C. Increased intracranial pressure
- D. Decreased intracranial pressure
Correct Answer: B
Rationale: The anterior fontanel is normally 2 to 3 cm in width, 3 to 4 cm in length, and diamond-like in shape. It can be described as soft, which is normal, or full and bulging, which could indicate increased intracranial pressure. Conversely a depressed fontanel could mean that the infant is dehydrated.
Which nursing assessment finding indicates the presence of an inguinal hernia on a child?
- A. Reports of difficulty defecating
- B. Reports of a dribbling urinary stream
- C. Absence of the testes within the scrotum
- D. Painless groin swelling noticed when the child cries
Correct Answer: D
Rationale: Inguinal hernia is a common defect that may appear as a painless inguinal (groin) swelling when the child cries or strains. Option 1 is a symptom indicating a partial obstruction of the herniated loop of intestine. Option 2 describes a sign of phimosis, a narrowing or stenosis of the preputial opening of the foreskin. Option 3 describes cryptorchidism.
The nurse is developing a plan of care for a client who suffered a pelvic fracture following a motor vehicle crash (MVC). Which interventions should be included in the nursing care plan to prevent skin breakdown? Select all that apply.
- A. Minimize the force and friction applied to the skin.
- B. Massage vigorously over bony prominences twice daily.
- C. Perform a systematic skin inspection at least once a day.
- D. Cleanse the skin at the time of soiling and at routine intervals.
- E. Use pillows to keep the knees and other bony prominences from direct contact with one another.
- F. Use hot water and a mild cleansing agent that minimizes irritation and dryness of the skin when bathing the client.
Correct Answer: A,C,D,E
Rationale: The client in this question is at high risk for pressure injury. Interventions for prevention of pressure injuries include minimizing the force and friction applied to the skin; performing a systematic skin inspection at least once a day, giving particular attention to the bony prominences; cleansing the skin at the time of soiling and at routine intervals; avoiding the use of hot water; and using a mild cleansing agent that minimizes irritation and dryness of the skin. Pillows should be used to keep the knees and other bony prominences from direct contact with one another, because skin contact can promote breakdown. Massaging over bony prominences (especially vigorous) can be harmful to at-risk skin surfaces.