Nokea
A client with diabetes is experiencing symptoms of hypoglycemia. What should the nurse administer first?
- A. 10 units of regular insulin subcutaneously
- B. 50 mL of 50% dextrose solution intravenously
- C. 1 mg of glucagon intramuscularly
- D. 15-20 grams of fast-acting carbohydrate orally
Correct Answer: D
Rationale: The correct answer is D: 15-20 grams of fast-acting carbohydrate orally. In hypoglycemia, the immediate goal is to raise blood glucose levels quickly. Fast-acting carbohydrates like glucose tablets or juice are the most effective and fastest way to raise blood sugar levels. Administering insulin (choice A) would further lower blood sugar levels. Intravenous dextrose (choice B) is appropriate for severe cases but may not be necessary as the first step. Glucagon (choice C) is typically used if the client is unconscious or unable to consume oral carbohydrates.
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Mary Thomas presents with red, teary eyes, a runny nose, and a stuffy head. What nursing orders would be recommended?
- A. Antihistamines, aspirin, and cough syrup
- B. Increased fluids, steam inhalation, and rest
- C. Aspirin, cough syrup, and increased fluids
- D. Auscultation and percussion of the chest
Correct Answer: B
Rationale: Hydration, steam inhalation, and rest help alleviate symptoms and promote recovery.
What is the purpose of the Weber test?
- A. To determine the type of hearing loss
- B. To measure intraocular pressure
- C. To assess color vision
- D. To evaluate pupil response
Correct Answer: A
Rationale: The Weber test helps differentiate between conductive and sensorineural hearing loss.
How does the pain of a myocardial infarction (MI) differ from stable angina?
- A. Accompanied by shortness of breath
- B. Feelings of fear or anxiety
- C. Lasts about 3-5 minutes
- D. Relieved by taking nitroglycerin
Correct Answer: A
Rationale: The correct answer is A, as the pain of MI is often accompanied by shortness of breath due to decreased oxygen supply to the heart muscle, whereas stable angina typically does not present with this symptom. Shortness of breath in MI is due to the heart's inability to pump effectively. Choices B, C, and D are incorrect because feelings of fear or anxiety, duration of pain, and response to nitroglycerin are not definitive differentiating factors between MI and stable angina.
Which is an indicator of escalating withdrawal used by a nurse when assessing a client with alcohol dependence?
- A. Rule of one hundreds
- B. CAGE screening test
- C. Alcoholics anonymous
- D. Rule of nines
Correct Answer: B
Rationale: The CAGE questionnaire screens for alcohol use disorders, identifying signs of dependency or problematic drinking.
A client is receiving discharge teaching after a total hip replacement. Which statement by the client indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I can sleep on my side as long as I use a pillow between my legs.
- C. I will avoid bending at the waist to pick things up.
- D. I can bend down to tie my shoes after 2 weeks.
Correct Answer: D
Rationale: The correct answer is D because bending down to tie shoes after only 2 weeks post total hip replacement can put strain on the hip joint and increase the risk of dislocation. The client should avoid bending past 90 degrees to protect the new hip joint. Choices A, B, and C are all correct statements as they promote hip joint protection and reduce the risk of complications.