Nokea
Laboratory Reference Ranges
Glucose – Fasting
70–110 mg/dL
(3.9–6.1 mmol/L)
A client with type 1 diabetes is prescribed NPH insulin before breakfast and dinner. Although the client reports feeling well, the 6 AM fasting blood glucose is 60 mg/dL. Which action should the nurse recommend to the client?
- A. Collect urine sample to check for urine ketones
- B. Consume a snack of milk and cereal at bedtime
- C. Increase carbohydrate intake at each meal
- D. Take only the prebreakfast dose of NPH
Correct Answer: B
Rationale: A fasting blood glucose of 60 mg/dL indicates hypoglycemia risk with NPH insulin, which peaks overnight. A bedtime snack prevents nocturnal hypoglycemia. Ketones are checked for hyperglycemia, increased carbohydrates may cause hyperglycemia, and skipping doses disrupts control.
You may also like to solve these questions
An adult client in an acute care setting asks the nurse to show him his hospital records. The nurse's response should reflect which understanding?
- A. The client has no right to see his records without a court order.
- B. The client must have the physician's approval before he can see his records.
- C. The client has the right to see his records and to have information explained when necessary.
- D. The client must ask permission to view his records from the medical records department and must appear before a special committee.
Correct Answer: C
Rationale: HIPAA grants clients the right to access their medical records and receive explanations, ensuring transparency. Court orders, physician approval, or committees are not required.
The parent of a 7-month-old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arms with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (situation, background, assessment, recommendation/read back) communication is most important for the nurse to report?
- A. Client has been ill for approximately 4 hours
- B. Client has improved from apparent earlier distress
- C. Client is now lethargic with abnormal vital signs
- D. Does the health care provider want to order a laxative?
Correct Answer: C
Rationale: The infant's lethargy with tachycardia (200/min) and tachypnea (60/min) are critical, suggesting a serious condition like intussusception or volvulus, requiring urgent reporting. Duration , perceived improvement , and laxative suggestion are less critical.
The nurse is caring for a client with spontaneous rupture of membranes. The nurse notes a loop of umbilical cord protruding from the vagina. Which of the following actions should the nurse take?
- A. Apply suprapubic pressure
- B. Perform Leopold maneuvers
- C. Perform the McRoberts maneuver
- D. Assist the client to the knee-chest position
Correct Answer: D
Rationale: Umbilical cord prolapse is an emergency requiring the knee-chest position to relieve cord compression. Suprapubic pressure and McRoberts are for shoulder dystocia, and Leopold maneuvers are for fetal positioning assessment.
The nurse is assessing a 1-month-old infant with atrial septal defect. Which of the following findings would be consistent with the condition?
- A. cyanosis
- B. muffled heart tones
- C. murmur
- D. weak femoral pulses
Correct Answer: C
Rationale: An atrial septal defect often presents with a heart murmur due to abnormal blood flow. Cyanosis is rare unless severe, muffled tones are not typical, and weak femoral pulses suggest coarctation of the aorta.
Which of the following tasks can the practical nurse (PN) safely assign to an experienced unlicensed assistive personnel (UAP)? Select all that apply.
- A. Ambulate an oxygen-dependent client to the bathroom
- B. Check pulse oximetry for a client with respiratory rate 12/min
- C. Instruct a client with pneumonia on usage of the incentive spirometer
- D. Provide oral hygiene to a client with chronic obstructive pulmonary disease (COPD)
- E. Turn and reposition a client with pneumonia
Correct Answer: A,B,D,E
Rationale: UAP can ambulate stable clients , check pulse oximetry , provide oral hygiene , and reposition clients . Instructing on incentive spirometry requires nursing judgment and is not delegable.