Nokea
A client with a history of type 1 diabetes is admitted with hypoglycemia. The nurse should administer which of the following if the client is conscious?
- A. Glucagon intramuscularly.
- B. 50% dextrose intravenously.
- C. Orange juice orally.
- D. Insulin subcutaneously.
Correct Answer: C
Rationale: Orange juice provides fast-acting carbohydrates to raise blood glucose in a conscious client with hypoglycemia.
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Which of the following diet instructions are appropriate when teaching a client in the early stages of cirrhosis about nutritional needs? Select all that apply.
- A. Limit your caloric intake so that you don't become overweight.'
- B. An adequate intake of protein is important to your health.'
- C. I encourage you to eat small, frequent meals.'
- D. Restrict your fluid intake to 1,000 mL/day.'
- E. Limit your alcohol intake to one glass of wine daily.'
Correct Answer: B,C
Rationale: Adequate protein supports liver repair, and small, frequent meals reduce metabolic stress in early cirrhosis. Alcohol should be avoided, and fluid restriction is not typically needed early on.
Which interventions should the nurse use to assist the client with grandiose delusions? Select all that apply.
- A. Accepting the client while not arguing with the delusion.
- B. Focusing on the feelings or meaning of the delusion.
- C. Focusing on events and topics based in reality.
- D. Confronting the client's beliefs.
- E. Interacting with the client only when he is based in reality.
Correct Answer: A,B,C
Rationale: To manage grandiose delusions, the nurse should accept the client without reinforcing the delusion, focus on the underlying feelings, and redirect to reality-based topics. Confronting beliefs or limiting interaction to reality-based moments can escalate agitation or alienate the client.
A client with a history of burns is admitted with a 40% total body surface area injury. The nurse should prioritize which of the following interventions?
- A. Initiate fluid resuscitation.
- B. Administer prophylactic antibiotics.
- C. Apply ice to the burns.
- D. Cover the burns with dry gauze.
Correct Answer: A
Rationale: Fluid resuscitation is the priority to prevent hypovolemic shock in extensive burns.
A client was admitted to the surgical unit after right total knee arthroscopy performed 2 hours earlier. Which surgeon's prescription requires clarification?
- A. Maintain right knee in a slightly flexed position.
- B. Implement patient-controlled analgesia (PCA) per my protocol.
- C. Place sequential compression devices on both legs while on bed rest.
- D. Notify physical therapy to begin isometric quadriceps exercises on the day following surgery.
Correct Answer: A
Rationale: The knee is immobilized by a compression dressing to keep the knee in extension immediately after the operation. The nurse should clarify a prescription to keep the knee slightly flexed. Pain control by use of patient-controlled analgesia, use of compression devices to reduce the risk of thromboembolism, and physical therapy to begin isometric quadriceps exercises are expected prescriptions after total knee arthroscopy surgery.
When using crutches, the client should be instructed to bear weight primarily on the:
- A. Axillae
- B. Elbows
- C. Upper arms
- D. Hands
Correct Answer: D
Rationale: Weight should be borne on the hands when using crutches to prevent nerve damage from pressure on the axillae. Elbows and upper arms are not primary weight-bearing areas.