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A client with a diagnosis of diabetes mellitus is experiencing symptoms of hypoglycemia. What is the nurse's priority intervention?
- A. Administer glucagon intramuscularly.
- B. Provide a complex carbohydrate snack.
- C. Administer 50% dextrose intravenously.
- D. Give 15 grams of a fast-acting carbohydrate.
Correct Answer: D
Rationale: The correct answer is to give 15 grams of a fast-acting carbohydrate as the priority intervention in a client experiencing hypoglycemia. This helps quickly raise the blood glucose level. Administering glucagon intramuscularly (Choice A) is typically reserved for severe hypoglycemia where the client is unable to take oral carbohydrates. Providing a complex carbohydrate snack (Choice B) is not the priority in an acute hypoglycemic episode where immediate action is needed. Administering 50% dextrose intravenously (Choice C) is more invasive and usually reserved for cases where the client is unable to take anything by mouth.
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A client with chronic obstructive pulmonary disease (COPD) is struggling to breathe. What should the nurse do first?
- A. Increase the oxygen flow rate according to the prescription
- B. Encourage the client to perform pursed-lip breathing
- C. Prepare for emergency intubation
- D. Assess the client's oxygen saturation and breath sounds
Correct Answer: D
Rationale: The correct first action for a nurse when a client with COPD is struggling to breathe is to assess the client's oxygen saturation and breath sounds. This initial assessment is crucial in determining the severity of the client's condition and the appropriate intervention. Increasing the oxygen flow rate without proper assessment can potentially be harmful, as COPD clients have a risk of retaining carbon dioxide. Encouraging pursed-lip breathing can be beneficial but should come after assessing the client's current status. Emergency intubation is a drastic measure and should only be considered after a comprehensive assessment indicates the need for it.
The nurse is assessing an older resident with a history of Benign Prostatic Hypertrophy and identifies a distended bladder. What should the nurse do?
- A. Stand the client to void and run tap water within hearing distance before catheterizing
- B. Straight catheterize and if the residual urine volume is greater than 100 mL, clamp catheter
- C. Catheterize q2h and place in an indwelling catheter at the end of the prescribed 24hr period
- D. Catheterize with an indwelling catheter and if the residual volume is greater than 100 mL, inflate the balloon
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A client is admitted with a diagnosis of congestive heart failure (CHF). Which intervention is most important to include in the plan of care?
- A. Restrict fluid intake
- B. Provide a high-sodium diet
- C. Encourage vigorous exercise
- D. Administer bronchodilators as prescribed
Correct Answer: A
Rationale: The correct answer is A: Restrict fluid intake. Fluid restriction is crucial in the management of congestive heart failure (CHF) as it helps prevent fluid overload, which can exacerbate CHF symptoms. Choices B, C, and D are incorrect. Providing a high-sodium diet would worsen fluid retention and increase the workload of the heart. Encouraging vigorous exercise can strain the heart further in CHF patients. Administering bronchodilators is not the priority intervention for CHF.
The nurse is assessing a client who has been receiving total parenteral nutrition (TPN) for several days. Which complication should the nurse monitor for?
- A. Hyperglycemia
- B. Hypoglycemia
- C. Hyponatremia
- D. Hypokalemia
Correct Answer: B
Rationale: The correct answer is B: Hypoglycemia. When a client is receiving total parenteral nutrition (TPN) with a high glucose content, the risk of hypoglycemia is significant due to sudden increases in insulin release in response to the glucose load. The nurse should monitor for signs and symptoms of hypoglycemia such as shakiness, sweating, palpitations, and confusion. Hyperglycemia (choice A) is not typically a complication of TPN as the high glucose content is more likely to cause hypoglycemia. Hyponatremia (choice C) and hypokalemia (choice D) are electrolyte imbalances that can occur in clients receiving TPN, but hypoglycemia is the more common and immediate concern that the nurse should monitor for.
The nurse is monitoring a client's intravenous infusion and observes that the venipuncture site is cool to the touch, swollen, and the infusion rate is slower than the prescribed rate. What is the most likely cause of this finding?
- A. The solution's rate is too rapid
- B. The client has phlebitis
- C. The infusion site is infected
- D. The infusion is infiltrated
Correct Answer: D
Rationale: The correct answer is D. An infiltrated IV occurs when fluid leaks into the surrounding tissue, causing coolness, swelling, and a slow infusion rate. Choice A is incorrect because a rapid solution rate does not typically cause these specific symptoms. Choice B, phlebitis, presents with redness, warmth, and tenderness along the vein, not coolness. Choice C, infection, usually manifests with redness, warmth, and possibly purulent drainage, not coolness and swelling.