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A client with newly diagnosed diabetes mellitus is being discharged home. Which statement indicates the client understands the instructions about managing blood glucose levels?
- A. I will test my blood glucose level once a week.
- B. I should eat a snack if my blood glucose is 70 mg/dl.
- C. If I feel shaky, I should take another dose of insulin.
- D. It's okay to skip a meal if I'm not hungry.
Correct Answer: B
Rationale: The correct answer is B because eating a snack when blood glucose is 70 mg/dl helps prevent hypoglycemia. Testing blood glucose once a week (A) is not frequent enough for proper management. Taking extra insulin when shaky (C) can lead to hypoglycemia. Skipping meals (D) can cause unstable blood glucose levels.
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A primipara at 38-weeks gestation is admitted to labor and delivery for a biophysical profile (BPP). The nurse should prepare the client for what procedures?
- A. Chorionic villus sampling under ultrasound.
- B. Amniocentesis and fetal monitoring.
- C. Ultrasonography and nonstress test.
- D. Oxytocin challenge test and fetal heart rate monitoring.
Correct Answer: C
Rationale: The correct answer is C: Ultrasonography and nonstress test. At 38 weeks gestation, a biophysical profile (BPP) is typically done to assess fetal well-being. Ultrasonography is used to evaluate fetal movements, tone, breathing movements, and amniotic fluid volume. The nonstress test assesses fetal heart rate in response to fetal movement, indicating fetal well-being. Chorionic villus sampling (A) and amniocentesis (B) are invasive procedures not typically done as part of a routine BPP. Oxytocin challenge test (D) is not indicated in this scenario as it is used to assess placental function in high-risk pregnancies.
The client has just been diagnosed with Addison's disease. Which clinical manifestation should the nurse expect to find?
- A. Hypertension and hyperglycemia.
- B. Hyperpigmentation and hypotension.
- C. Exophthalmos and tachycardia.
- D. Weight gain and fluid retention.
Correct Answer: B
Rationale: The correct answer is B: Hyperpigmentation and hypotension. Addison's disease is characterized by adrenal insufficiency, leading to low cortisol and aldosterone levels. Hyperpigmentation occurs due to elevated levels of ACTH, causing melanin deposition. Hypotension results from aldosterone deficiency, leading to sodium and water loss. Choice A is incorrect because Addison's disease does not typically present with hypertension or hyperglycemia. Choice C is incorrect as exophthalmos and tachycardia are not typically associated with Addison's disease. Choice D is incorrect as weight gain and fluid retention are not common manifestations of Addison's disease.
In which situation is it most important for the registered nurse (RN) working on a medical unit to provide direct supervision?
- A. A graduate nurse needs to access a client's implanted port to start an infusion of Ringer's Lactate.
- B. A postpartum nurse pulled to the unit needs to start a transfusion of packed red blood cells.
- C. A practical nurse is preparing to assist the healthcare provider with a lumbar puncture at the bedside.
- D. An unlicensed assistive personnel is preparing to weigh an obese bedfast client using a bed scale.
Correct Answer: A
Rationale: The correct answer is A because accessing an implanted port for infusion is a specialized skill that requires direct supervision to ensure the safety and accuracy of the procedure. Step 1: A graduate nurse may not have sufficient experience with accessing ports. Step 2: The RN needs to ensure proper technique and prevent complications. Step 3: Direct supervision allows for immediate intervention if any issues arise. Other choices are incorrect because B: starting a transfusion is within the scope of practice for a nurse, C: assisting with a lumbar puncture can be done under indirect supervision, and D: weighing a client is a task that can be delegated to unlicensed personnel with proper training.
A client from a nursing home is admitted with urinary sepsis and has a single-lumen, peripherally-inserted central catheter (PICC). Four medications are prescribed for 9:00 a.m. and the nurse is running behind schedule. Which medication should the nurse administer first?
- A. Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours.
- B. Vancomycin (Vancocin) 1 gm in 250 ml D5W, IV over 90 minutes q12 hours.
- C. Pantoprazole (Protonix) 40 mg PO daily.
- D. Enoxaparin (Lovenox) 40 mg subq q24 hours.
Correct Answer: A
Rationale: The correct answer is A: Piperacillin/tazobactam (Zosyn) in 100 ml D5W, IV over 30 minutes q8 hours. In a patient with urinary sepsis, timely administration of antibiotics is crucial to prevent further complications. Piperacillin/tazobactam is a broad-spectrum antibiotic effective against a wide range of bacteria commonly involved in sepsis. Administering it first ensures prompt initiation of treatment. Other choices (B) Vancomycin, (C) Pantoprazole, and (D) Enoxaparin are important medications but are not as time-sensitive in this scenario. Vancomycin and Enoxaparin have longer administration times, and Pantoprazole is a maintenance medication that is not urgent in the acute management of sepsis.
The healthcare provider is caring for a client with a chest tube. Which assessment finding requires immediate intervention?
- A. Intermittent bubbling in the water seal chamber.
- B. Drainage of 75 ml in the first hour post-insertion.
- C. Crepitus around the insertion site.
- D. Fluctuation of the water level in the water seal chamber with respiration.
Correct Answer: C
Rationale: The correct answer is C: Crepitus around the insertion site. Crepitus suggests subcutaneous emphysema, which can indicate a pneumothorax or air leak. Immediate intervention is needed to prevent further complications.
A: Intermittent bubbling in the water seal chamber is expected and indicates a functioning chest tube system.
B: Drainage of 75 ml in the first hour post-insertion is within the normal range and should be monitored.
D: Fluctuation of the water level in the water seal chamber with respiration is a normal finding indicating the chest tube is functioning correctly.