Nokea
A client with a history of type 1 diabetes is admitted with hyperglycemia. The nurse should include which of the following in the plan of care?
- A. Administer regular insulin as prescribed.
- B. Restrict fluid intake.
- C. Encourage a high-carbohydrate diet.
- D. Administer glucagon.
Correct Answer: A
Rationale: Regular insulin corrects hyperglycemia in type 1 diabetes.
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A client newly diagnosed with angina pectoris has taken two sublingual nitroglycerin tablets for chest pain. The chest pain is relieved, but the client now reports a headache. The nurse interprets that this most likely represents which response?
- A. An early sign of medication tolerance
- B. An allergic reaction to the nitroglycerin
- C. An expected side effect of the medication
- D. A warning that the medication should not be used again
Correct Answer: C
Rationale: Headache is a frequent side effect of nitroglycerin, because of the vasodilating action of the medication. It usually diminishes in frequency as the client becomes accustomed to the medication and is effectively treated with acetaminophen. The other options are incorrect.
The nurse administers an intradermal injection to a client. Proper technique has been used if the injection site demonstrates which of the following?
- A. No swelling.
- B. Tissue pallor.
- C. Evidence of a bleb.
- D. Erythema.
Correct Answer: C
Rationale: A bleb (small wheal) at the injection site indicates correct intradermal technique, as the medication is deposited just under the skin.
A client with a history of cirrhosis is prescribed propranolol (Inderal). The nurse should monitor the client for which of the following therapeutic effects?
- A. Decreased portal hypertension.
- B. Increased blood glucose.
- C. Decreased ammonia levels.
- D. Increased platelet count.
Correct Answer: A
Rationale: Propranolol reduces portal hypertension by decreasing portal vein pressure in cirrhosis.
The nurse recognizes that a client with pain disorder is improving when the client says which of the following?
- A. I need to have a good cry about all the pain I've been in and then not dwell on it.'
- B. I need to find another physician who can accurately diagnose my condition.'
- C. The pain medicine that you gave me helps me to relax.'
- D. I'm angry with all of the doctors I've seen who don't know what they're doing.'
Correct Answer: A
Rationale: Expressing a desire to process emotions and move forward indicates improved coping, a sign of progress in managing pain disorder.
A primigravid client at 38 weeks' gestation reports decreased fetal movement. What is the nurse's first action?
- A. Perform a nonstress test.
- B. Notify the physician.
- C. Encourage the client to drink water.
- D. Auscultate fetal heart tones.
Correct Answer: D
Rationale: Auscultating fetal heart tones is the first step to assess fetal well-being in response to decreased movement, providing immediate data.