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A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?
- A. Administer insulin as prescribed
- B. Provide a carbohydrate-controlled snack
- C. Encourage physical activity
- D. Recheck the blood sugar
Correct Answer: A
Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.
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The nurse is caring for a client with a history of seizure disorder who is receiving phenytoin (Dilantin). Which laboratory value is most important to monitor?
- A. Phenytoin level
- B. Sodium level
- C. Hemoglobin level
- D. White blood cell count
Correct Answer: A
Rationale: Corrected Rationale: Monitoring the phenytoin level is crucial to ensure it is within the therapeutic range and to prevent toxicity. Monitoring sodium level is important in clients receiving lithium, not phenytoin. Hemoglobin level and white blood cell count are not directly related to phenytoin therapy monitoring.
A client with a diagnosis of heart failure is receiving furosemide (Lasix). Which electrolyte imbalance should the nurse monitor for?
- A. Hyperkalemia.
- B. Hyponatremia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: The correct answer is D: Hypokalemia. Furosemide is a loop diuretic that can cause potassium loss, leading to hypokalemia. Therefore, the nurse should monitor the client for low potassium levels. Choice A, Hyperkalemia, is incorrect as furosemide does not typically cause high potassium levels. Choice B, Hyponatremia, is incorrect as furosemide primarily affects potassium levels, not sodium. Choice C, Hypocalcemia, is incorrect as furosemide does not directly impact calcium levels.
What is the most important information for the nurse to provide to a client with a diagnosis of major depressive disorder who is started on a selective serotonin reuptake inhibitor (SSRI)?
- A. Take the medication with food
- B. Avoid foods high in tyramine
- C. Report any thoughts of self-harm immediately
- D. Expect to see improvement within 24 hours
Correct Answer: C
Rationale: The correct answer is C: 'Report any thoughts of self-harm immediately.' When starting an SSRI, clients should be informed to report any thoughts of self-harm promptly. SSRIs can initially increase suicidal ideation, especially in the early stages of treatment. This information is crucial for the client's safety and well-being. Choices A, B, and D are incorrect because taking the medication with food, avoiding foods high in tyramine, and expecting immediate improvement within 24 hours are not the most critical pieces of information for a client starting on an SSRI.
The nurse is caring for a client with an indwelling urinary catheter. What is the most important action to prevent catheter-associated urinary tract infections (CAUTI)?
- A. Perform hand hygiene before and after handling the catheter
- B. Change the catheter every 72 hours
- C. Apply antibiotic ointment at the insertion site
- D. Irrigate the catheter daily
Correct Answer: A
Rationale: Performing hand hygiene before and after handling the catheter is crucial in preventing catheter-associated urinary tract infections (CAUTI). This practice helps minimize the risk of introducing harmful microorganisms into the urinary tract. Changing the catheter every 72 hours is not recommended unless clinically indicated as it can increase the risk of infection. Applying antibiotic ointment at the insertion site is not a standard practice and may contribute to antibiotic resistance. Irrigating the catheter daily is unnecessary and can introduce pathogens into the urinary tract, increasing the risk of infection.
Which organ lies retroperitoneally?
- A. Kidneys
- B. Testicles
- C. Urinary bladder
- D. Pancreas
Correct Answer: A
Rationale: The correct answer is A: Kidneys. The kidneys are located retroperitoneally, behind the peritoneum, providing structural protection and maintaining a stable position within the abdominal cavity. This location helps protect them from external physical trauma. Choices B, C, and D are incorrect because testicles, urinary bladder, and pancreas are not located retroperitoneally. Testicles are located in the scrotum, the urinary bladder is located in the pelvis, and the pancreas is located in the upper abdomen, not retroperitoneally.