Nokea
A client with diabetes is explaining to the nurse how she will care for her feet at home. Which statement indicates that the client understands proper foot care?
- A. When I injure my toe, I will plan to put iodine on it.'
- B. I should inspect my feet at least once a week.'
- C. It is okay to go barefoot in the house.'
- D. It is important to dry my feet carefully after my bath.'
Correct Answer: D
Rationale: Thorough drying prevents moisture-related infections, critical for diabetic foot care to avoid complications like ulcers.
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The nurse is ready to administer a partial fill of imipenem-cilastatin (Primaxin) in the I.V. pump when a full partial fill bag of imipenem-cilastatin is found hanging at the client's bedside. Which of the following is not appropriate to do by the nurse when recognizing that the previous dose was not administered 8 hours ago to the client with pneumonia?
- A. Discard the full partial fill of imipenem-cilastatin found hanging at the client's bedside.
- B. Check the identifying information of the full partial fill of imipenem-cilastatin found hanging at the client's bedside.
- C. Follow up on the legal documentation of the client's previous administration of imipenem-cilastatin.
- D. Administer the new partial fill of imipenem-cilastatin.
Correct Answer: A
Rationale: Discarding the medication without investigation is inappropriate; the nurse should verify, document, and address the error appropriately.
The nurse is planning to assist the physician with a thoracentesis for a client who has a pleural effusion. Which of the following positions would be appropriate for the client to assume?
- A. Lying supine with the arms extended.
- B. Lying prone with the head supported by the arms.
- C. Sitting upright and leaning on an overbed table.
- D. Side-lying with the knees drawn up to the abdomen.
Correct Answer: C
Rationale: Sitting upright and leaning on an overbed table facilitates access to the pleural space and ensures client comfort during thoracentesis.
The nurse is assessing a neonate born to a diabetic mother. Which of the following findings should the nurse expect to see in the infant?
- A. Hypertonia
- B. Hyperactivity
- C. Large size
- D. Scaly skin
Correct Answer: C
Rationale: Neonates born to diabetic mothers are often macrosomic (large size) due to maternal hyperglycemia. Hypertonia, hyperactivity, and scaly skin are not typical findings.
The nurse reviews the serum laboratory results for a client prescribed hydrochlorothiazide. Which most frequent side effect of this medication should the nurse specifically monitor for?
- A. Hypokalemia
- B. Hypocalcemia
- C. Hypernatremia
- D. Hyperphosphatemia
Correct Answer: A
Rationale: The client taking a potassium-losing diuretic must be monitored for decreased potassium levels. Other fluid and electrolyte imbalances that occur with the use of this medication include hyponatremia, hypercalcemia, hypomagnesemia, and hypophosphatemia.
The nurse is assessing a client with a suspected bowel obstruction. Which of the following findings is most indicative of this condition?
- A. Abdominal distension.
- B. Decreased bowel sounds.
- C. Soft, nontender abdomen.
- D. Frequent loose stools.
Correct Answer: A,B
Rationale: Abdominal distension and decreased bowel sounds are hallmark signs of bowel obstruction due to blocked intestinal passage.