Nokea
A client with type 1 diabetes mellitus is admitted with diabetic ketoacidosis (DKA). Which of the following interventions should be the nurse's priority?
- A. Administer intravenous insulin
- B. Start an intravenous line and infuse normal saline
- C. Monitor serum potassium levels
- D. Obtain an arterial blood gas (ABG)
Correct Answer: B
Rationale: The correct answer is to start an intravenous line and infuse normal saline. In diabetic ketoacidosis (DKA), the priority intervention is fluid resuscitation with normal saline to restore intravascular volume and improve perfusion. Administering insulin without first addressing dehydration and electrolyte imbalances can lead to further complications. Monitoring serum potassium levels and obtaining an arterial blood gas (ABG) are important aspects of DKA management but come after initial fluid resuscitation.
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When implementing a new policy on the unit, what process should a nurse manager follow?
- A. The nurse manager should involve staff members in the decision-making process, gather input, and communicate the reasons for the policy change to ensure buy-in from the team.
- B. The nurse manager should implement the policy change immediately and monitor staff compliance to ensure that the new policy is being followed.
- C. The nurse manager should delegate the implementation of the policy change to a staff member and provide support as needed to ensure that the change is successful.
- D. The nurse manager should communicate the policy change to staff members, provide training as needed, and monitor the implementation process to ensure that the change is effective.
Correct Answer: A
Rationale: When introducing a new policy on the unit, it is essential for the nurse manager to involve staff members in the decision-making process. This approach helps in gathering input and insights from the team, fostering a sense of ownership and commitment. By communicating the reasons behind the policy change, the nurse manager ensures transparency and promotes understanding among the staff, leading to buy-in and acceptance of the new policy. Choice B is incorrect because implementing a policy change without involving staff and explaining the rationale may lead to resistance or lack of understanding. Choice C is not ideal as delegation without active involvement and communication with the team may result in misunderstandings or incomplete implementation. Choice D lacks the crucial step of involving staff in the decision-making process, which is important for successful policy implementation and team engagement.
A client with hypoparathyroidism is at risk for which of the following complications?
- A. Hypercalcemia
- B. Hypocalcemia
- C. Hyperkalemia
- D. Hypernatremia
Correct Answer: B
Rationale: Hypoparathyroidism is characterized by decreased levels of parathyroid hormone, leading to reduced calcium levels in the blood, which results in hypocalcemia. Therefore, the correct answer is B. Choices A, C, and D are incorrect because hypoparathyroidism does not typically lead to hypercalcemia, hyperkalemia, or hypernatremia. Hypercalcemia is more commonly associated with hyperparathyroidism, where there is excess secretion of parathyroid hormone.
A client with Graves' disease is prescribed propranolol. The nurse understands that the purpose of this medication is to:
- A. Treat the underlying cause of the disease
- B. Reduce thyroid hormone production
- C. Alleviate symptoms such as tachycardia and tremors
- D. Increase energy levels
Correct Answer: C
Rationale: The correct answer is C: Alleviate symptoms such as tachycardia and tremors. Propranolol is a beta-blocker that helps manage symptoms like tachycardia (fast heart rate) and tremors in patients with Graves' disease. Choice A is incorrect because propranolol does not address the underlying cause of Graves' disease, which is autoimmune in nature. Choice B is incorrect because propranolol does not directly reduce thyroid hormone production; it mainly targets the symptoms. Choice D is incorrect because while propranolol may help with symptoms like tachycardia, it is not intended to increase energy levels.
Which of the following symptoms would be most concerning in a client with diabetes insipidus?
- A. Polydipsia
- B. Polyuria
- C. Nocturia
- D. Hypertension
Correct Answer: D
Rationale: In a client with diabetes insipidus, excessive thirst (polydipsia) and excessive urination (polyuria) are expected symptoms due to the inability to concentrate urine, leading to dilute urine production. Nocturia, waking up at night to urinate, is also common. However, hypertension is not a typical symptom of diabetes insipidus. The correct answer is D because hypertension may indicate a complication such as dehydration or electrolyte imbalances, which would require further assessment in a client with diabetes insipidus.
In a 29-year-old female client who is being successfully treated for Cushing's syndrome, nurse Lyzette would expect a decline in:
- A. Serum glucose level.
- B. Hair loss.
- C. Bone mineralization.
- D. Menstrual flow.
Correct Answer: A
Rationale: The correct answer is A: Serum glucose level. In Cushing's syndrome, there is excess cortisol production which can lead to hyperglycemia. Successful treatment of Cushing's syndrome aims to normalize cortisol levels, resulting in a decline in serum glucose levels. Choice B, hair loss, is not specifically associated with Cushing's syndrome or its treatment. Choice C, bone mineralization, is often compromised in Cushing's syndrome due to the effects of excess cortisol on bones; however, successful treatment would aim to improve bone health rather than decline it. Choice D, menstrual flow, is not directly linked to Cushing's syndrome or its treatment, so a decline in menstrual flow would not be an expected outcome of successful treatment.