Nokea
A client with acute pancreatitis is put on nothing-by-mouth status, with the intent of not stimulating the pancreas. The client is prescribed an I.V. infusion of dextrose 5% in half-normal saline solution at 120 mL/hour. After 3 days of this regimen, the nurse should observe the client for which of the following metabolic conditions?
- A. Ketosis.
- B. Hyperglycemia.
- C. Metabolic syndrome.
- D. Lactic acidosis.
Correct Answer: B
Rationale: Dextrose 5% infusion can lead to hyperglycemia, especially in a client with acute pancreatitis, requiring monitoring.
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The nurse is assessing a child admitted with a diagnosis of rheumatic fever. Which significant question should the nurse ask the child's parent during the assessment?
- A. Has your child had difficulty urinating?
- B. Has your child been exposed to anyone with chickenpox?
- C. Has any family member had a sore throat within the past few weeks?
- D. Has any family member had a gastrointestinal disorder in the past few weeks?
Correct Answer: C
Rationale: Rheumatic fever characteristically presents 2 to 6 weeks after an untreated or partially treated group A beta-hemolytic streptococcal infection of the respiratory tract. Initially the nurse determines whether any family member has had a sore throat or unexplained fever within the past few weeks. The remaining options are unrelated to the assessment findings of rheumatic fever.
The nurse assesses for euphoria in a client with multiple sclerosis, looking for which of the following characteristic clinical manifestations?
- A. Inappropriate laughter.
- B. An exaggerated sense of well-being.
- C. Slurring of words when excited.
- D. Visual hallucinations.
Correct Answer: B
Rationale: Euphoria in multiple sclerosis is characterized by an exaggerated sense of well-being, often disproportionate to the client's condition.
A client with a history of type 1 diabetes is admitted with diabetic ketoacidosis. The nurse should prioritize which of the following interventions?
- A. Administer regular insulin intravenously.
- B. Administer potassium supplements.
- C. Restrict fluid intake.
- D. Administer sodium bicarbonate.
Correct Answer: A
Rationale: Intravenous regular insulin is the priority to lower blood glucose and halt ketogenesis in diabetic ketoacidosis.
The nurse is caring for a client with a new diagnosis of glaucoma. Which medication class should the nurse expect to administer?
- A. Beta-blockers
- B. Antibiotics
- C. Corticosteroids
- D. Antihistamines
Correct Answer: A
Rationale: Beta-blockers, such as timolol, reduce intraocular pressure in glaucoma by decreasing aqueous humor production, the primary treatment goal.
A client is trying to lose weight at a moderate pace. The client eliminates 1,000 calories per day from his normal intake, how many pounds would he lose in 1 week?
- A. 2
- B. 3
- C. 4
- D. 5
Correct Answer: A
Rationale: A 1,000-calorie daily deficit equals 7,000 calories per week. Since 3,500 calories approximate one pound of fat, the client would lose about 2 pounds per week.