Nokea
A client with DM has an above-knee amputation because of severe peripheral vascular disease. Two days following surgery, when preparing the client for dinner, what is the nurse's primary responsibility?
- A. Check the client's serum glucose level
- B. Assist the client out of bed to the chair
- C. Place the client in a high-Fowler's position
- D. Ensure that the client's residual limb is elevated
Correct Answer: A
Rationale: The correct answer is to check the client's serum glucose level. In a client with diabetes who just had surgery, monitoring the serum glucose level is crucial to ensure proper management of the condition. This helps in preventing complications related to blood sugar fluctuations. Assisting the client out of bed may be important but not the primary responsibility at this time. Placing the client in a high-Fowler's position or ensuring the residual limb is elevated are important interventions for comfort and circulation but are not the primary concern in this scenario.
You may also like to solve these questions
How many calories per kilogram does an average full-term infant require when the infant is around 1-2 months old?
- A. 140 calories per kilogram per day
- B. 120 calories per kilogram per day
- C. 100 calories per kilogram per day
- D. 160 calories per kilogram per day
Correct Answer: B
Rationale: An average full-term infant requires about 120 calories per kilogram per day at 1-2 months old. This amount is essential for their growth and development during this critical stage. Choices A, C, and D are incorrect as they provide calorie amounts that are either too high or too low for an average full-term infant at 1-2 months old, which could potentially lead to health issues or inadequate nutrition.
Which anatomic malformations are associated with Tetralogy of Fallot?
- A. A sub-aortic septal defect, an overriding aorta, left ventricular hypertrophy, and right ventricular outflow
- B. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and left ventricular outflow
- C. A sub-aortic septal defect, an overriding aorta, pulmonary atresia, and right ventricular outflow
- D. A sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow
Correct Answer: D
Rationale: Tetralogy of Fallot is characterized by a combination of four heart defects: a sub-aortic septal defect, an overriding aorta, right ventricular hypertrophy, and right ventricular outflow obstruction. This leads to mixing of oxygen-poor and oxygen-rich blood, resulting in cyanosis. Therefore, the correct answer is D. Choices A, B, and C are incorrect because they do not accurately describe the specific combination of anatomic malformations seen in Tetralogy of Fallot.
A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?
- A. You should contact the provider about your wishes for your family member.
- B. We'll need to have the nursing supervisor review the client's advance directives.
- C. You should speak with the facility's ethics committee about your concerns.
- D. As the health care surrogate, the client's partner can make this decision.
Correct Answer: D
Rationale: The correct response is D because the health care surrogate, as designated by the client, has the legal authority to make healthcare decisions on behalf of the client when they are unable to do so. This authority includes decisions about treatment continuation or withdrawal. Option A is incorrect as the family member's wishes do not override the legal authority of the health care surrogate. Option B is not the most appropriate action in this situation as the advance directives are already clear by the designation of a health care surrogate. Option C is not necessary at this stage since the health care surrogate can make the decision without involving the ethics committee.
A hospice nurse is caring for a client who has a terminal illness and reports severe pain. After the nurse administers the prescribed opioid and benzodiazepine, the client becomes somnolent and difficult to arouse. Which of the following actions should the nurse take?
- A. Withhold the benzodiazepine but continue the opioid
- B. Contact the provider about replacing the opioid with an NSAID
- C. Administer the benzodiazepine but withhold the opioid
- D. Continue the medication dosages that relieve the client's pain
Correct Answer: B
Rationale: The correct action for the nurse to take is to contact the provider about replacing the opioid with an NSAID. In this scenario, the client is experiencing excessive sedation after the administration of both opioid and benzodiazepine. Switching to a non-opioid analgesic like an NSAID can help manage pain effectively without causing additional sedation. Option A is incorrect because continuing the opioid may exacerbate sedation. Option C is incorrect as administering the benzodiazepine may further increase sedation. Option D is incorrect because maintaining the current medication dosages that are causing excessive sedation is not in the client's best interest.
You are caring for a patient who has no cognitive functioning but only basic human functions such as opening the eyes and the sleep-wake cycle. What level of consciousness does this patient have?
- A. Obtunded
- B. A persistent vegetative state
- C. Locked-in syndrome
- D. Brain death
Correct Answer: B
Rationale: A persistent vegetative state is characterized by the absence of cognitive functioning while basic human functions like the sleep-wake cycle are retained. In this state, the patient shows reflex movements and basic responses to stimuli but lacks awareness or higher mental functions. Choices A, C, and D are incorrect because:
A) Obtunded refers to a decreased level of consciousness, not the absence of cognitive functioning.
C) Locked-in syndrome is a condition where the patient is aware and awake but cannot move or communicate due to complete paralysis of nearly all voluntary muscles except for vertical eye movements and blinking.
D) Brain death is the irreversible cessation of all brain activity, including the brainstem, leading to the loss of all functions of the brain.