Nokea
A client with type 1 diabetes mellitus is admitted to the emergency department. Which of the following respiratory patterns requires immediate action?
- A. Deep, rapid respirations with long expirations.
- B. Shallow respirations alternating with long expirations.
- C. Regular depth of respirations with frequent pauses.
- D. Short expirations and inspirations.
Correct Answer: A
Rationale: Deep, rapid respirations (Kussmaul respirations) indicate diabetic ketoacidosis, a life-threatening condition requiring immediate intervention.
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A client with terminal cancer expresses fear of dying alone. The nurse's most therapeutic response is:
- A. You won't be alone; we'll ensure someone is with you.
- B. Everyone dies alone, but it's not something to fear.
- C. Let's focus on keeping you comfortable instead.
- D. Have you considered spiritual counseling?
Correct Answer: A
Rationale: Assuring the client that someone will be present addresses their fear directly, providing emotional reassurance and support.
The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms:
- A. To the client from sources outside the client's environment.
- B. From the client to health care personnel, visitors, and other clients.
- C. By using special techniques to dispose of contaminated materials.
- D. By using special techniques to handle the client's linens and personal items.
Correct Answer: A
Rationale: Reverse isolation protects severely neutropenic clients by preventing the introduction of pathogens from external sources, such as staff, visitors, or equipment. It is not about preventing spread from the client or specific disposal/handling techniques.
The primary goal for the client with Buerger's disease is to prevent:
- A. Embolus formation
- B. Fat embolus formation
- C. Thrombophlebitis
- D. Gangrene
Correct Answer: D
Rationale: The primary goal in Buerger's disease is to prevent gangrene, as the condition causes severe arterial and venous inflammation, leading to occlusion and tissue ischemia. Smoking cessation and vasodilation are key to avoiding tissue necrosis. Embolus, fat embolus, or thrombophlebitis are less specific concerns.
The nurse is applying a prescribed 5% lidocaine patch to a client's lumbar back region. The nurse plans to remove this patch after how many hours following the application?
- A. 24 hours
- B. 72 hours
- C. 8 hours
- D. 12 hours
Correct Answer: D
Rationale: Lidocaine patches (5%) are typically applied for 12 hours and then removed for 12 hours to prevent skin irritation and systemic absorption, per standard guidelines.
After teaching the client with rheumatoid arthritis about measures to conserve energy in activities of daily living involving the small joints, which of the following, if stated by the client, would indicate the need for additional teaching?
- A. Pushing with palms when rising from a chair.
- B. Holding packages close to the body.
- C. Sliding objects.
- D. Carrying a laundry basket with clinched fingers and fists.
Correct Answer: D
Rationale: Carrying heavy loads with clinched fingers stresses small joints, increasing pain and deformity risk. The other actions minimize joint strain.