Nokea
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse should assess the client for which of the following signs of diabetic ketoacidosis (DKA)? Select all that apply.
- A. Fruity breath odor.
- B. Kussmaul respirations.
- C. Bradycardia.
- D. Polyuria.
- E. Hypotension.
Correct Answer: A, B, D, E
Rationale: DKA presents with fruity breath (due to acetone), Kussmaul respirations (compensatory hyperventilation), polyuria (osmotic diuresis), and hypotension (dehydration). Bradycardia is not typical.
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The nurse is assessing a client with a suspected tension pneumothorax. Which of the following interventions is the highest priority?
- A. Administer oxygen.
- B. Prepare for needle decompression.
- C. Obtain a chest X-ray.
- D. Start an IV line.
Correct Answer: B
Rationale: Preparing for needle decompression is the highest priority in tension pneumothorax to relieve pressure and restore lung function.
A 1-year-old is brought to the clinic with failure to thrive. Which assessment should the nurse prioritize?
- A. Dietary intake history
- B. Motor milestone development
- C. Head circumference
- D. Skin turgor
Correct Answer: A
Rationale: Dietary intake history is critical in failure to thrive to identify inadequate caloric intake or feeding issues, guiding intervention.
When witnessing an adult client's signature on a consent for a procedure, the nurse verifies that the consent was obtained in an appropriate manner. The nurse should verify which of the following? Select all that apply.
- A. That there was adequate disclosure of information.
- B. That the client understood the information.
- C. That there was voluntary consent on the client's part.
- D. That the client has full awareness of the potential complications.
- E. That the client's relative, spouse or legal guardian was present.
Correct Answer: A,B,C,D
Rationale: Informed consent requires adequate disclosure, client understanding, voluntary consent, and awareness of complications. A relative's presence is not mandatory unless the client is incapacitated.
A client develops an irregular heart rate. Which statement made by the client who has developed an irregular heart rate indicates to the nurse that the client is ready for learning?
- A. I feel weak with an irregular pulse.
- B. What is it like to have a pacemaker?
- C. All my medications will be changed now.
- D. How can this heart rate problem affect me?
Correct Answer: D
Rationale: Learning depends on two things: physical and emotional readiness to learn. A good time to teach is when the client indicates an interest in learning, is motivated, and is physically capable of concentrating on learning. Option 4 addresses the client's readiness because the client is directly asking about the disorder. Option 1 indicates that the client is potentially physically incapable of learning at this time. The client indicates wanting to learn about pacemakers in option 2; however, the client has formed a hasty conclusion because the need for a pacemaker has not been determined. In option 3, by assuming that the medications will change, the client is emotionally unprepared for learning because the statement is based on incomplete data.
The nurse is teaching a client who is taking cyclosporine after renal transplant about medication information. The nurse should tell the client to be especially alert for which problem?
- A. Hair loss
- B. Weight loss
- C. Hypotension
- D. Signs of infection
Correct Answer: D
Rationale: Cyclosporine is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication and report them to the primary health care provider if experienced. The client is also taught about other side/adverse effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints. Some weight loss may occur, but this is not as significant as the onset of an infection.