Nokea
A client with newly diagnosed type I diabetes mellitus is being seen by the home health nurse.
- A. What symptoms should the nurse expect in a client with type I diabetes and a blood sugar of 50 mg/dL?
- B. Confused with cold, clammy skin and a pulse of 110.
- C. Lethargic with hot, dry skin and rapid, deep respirations.
- D. Alert and cooperative with a BP of 130/80 and respirations of 1
- E. Short of breath, with distended neck veins and a bounding pulse of 96.
Correct Answer: A
Rationale: A blood sugar of 50 mg/dL indicates hypoglycemia, characterized by confusion, cold, clammy skin, and tachycardia (pulse 110) due to sympathetic activation. Hyperglycemia causes hot, dry skin and rapid respirations, while normal or fluid overload symptoms do not apply.
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A client has returned from surgery with a fine, reddened rash noted around the area where Betadine prep had been applied prior to surgery. Nursing documentation in the chart should include
- A. the time and circumstances under which the rash was noted.
- B. the explanation given to the client and family of the reason for the rash.
- C. notation on an allergy list and notification of the doctor.
- D. the need for application of corticosteroid cream to decrease inflammation.
Correct Answer: C
Rationale: suspected reaction to drugs should be reported to the doctor and noted on list of possible allergies
A postoperative client has pain medication ordered PRN for discomfort. During the first assessment, the nurse notes that the client has not received pain medication all day. His vital signs are within normal limits, but he is sweating profusely. He smiles at you while speaking and states that he is not hot but is still experiencing some pain and has been since early this morning. What is the most appropriate nursing action?
- A. Administer the largest dose of pain medication allowed because he has been without it all day and then allow him to rest undisturbed.
- B. Administer the minimum dose of medication and reassess his level of pain 30 minutes after administration.
- C. Hold the pain medication because his vital signs are within normal limits and he is smiling and showing no evidence of being in pain.
- D. Encourage the client to continue to do without pain medication so he won't become addicted to the opioid.
Correct Answer: B
Rationale: Administering the minimum dose and reassessing ensures effective pain management while monitoring response, given diaphoresis and reported pain.
The client is to be discharged after passing a uric acid kidney stone. This is the third time the client has been hospitalized for kidney stones. The nurse should teach the client to do which of the following?
- A. Eat generous amounts of chicken and organ meats
- B. Drink lots of water
- C. Avoid vigorous activity
- D. Take the ordered allopurinol (Zyloprim) if the symptoms recur
Correct Answer: B
Rationale: Increased fluid intake (lots of water) prevents stone formation by diluting urine. High-purine foods (meats), activity avoidance, or conditional allopurinol are incorrect.
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously q12h. The nurse should monitor for which of the following as a side effect?
- A. Increased urine output.
- B. Bruising at the injection site.
- C. Elevated blood pressure.
- D. Nausea and vomiting.
Correct Answer: B
Rationale: Heparin can cause bruising at injection sites due to its anticoagulant effect. Options A, C, and D are not typical side effects.
The nurse is caring for a client with a history of multiple sclerosis.
- A. Which symptom is expected in a client with multiple sclerosis?
- B. Chest pain and shortness of breath.
- C. Muscle weakness and spasticity.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Muscle weakness and spasticity are common in multiple sclerosis due to demyelination of nerve fibers. Chest pain, edema, and headaches are not typical symptoms.