Nokea
A client with type 1 diabetes mellitus is admitted with hyperglycemia. The nurse administers regular insulin as ordered. When should the nurse expect the insulin to begin acting?
- A. 15 to 30 minutes
- B. 1 to 2 hours
- C. 2 to 4 hours
- D. 4 to 6 hours
Correct Answer: A
Rationale: Regular insulin, a short-acting insulin, typically begins acting within 15 to 30 minutes after subcutaneous administration, making it effective for rapid blood glucose control.
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A newborn infant is diagnosed with imperforate anus. Which description of this disorder should the nurse provide to the parents?
- A. The presence of fecal incontinence
- B. Incomplete development of the anus
- C. The infrequent and difficult passage of dry stools
- D. Invagination of a section of the intestine into the distal bowel
Correct Answer: B
Rationale: Imperforate anus (anal atresia, anal agenesis) is the incomplete development or absence of the anus in its normal position in the perineum. Option 1 describes encopresis. Encopresis generally affects preschool and school-age children. Option 3 describes constipation. Constipation can affect any child at any time, although it peaks at age 2 to 3 years. Option 4 describes intussusception.
As you are assessing the fetus during labor you are determining and the fetal lie, presentation, attitude, station and position. Your client asks you what all these assessments are. Among other things, how should you respond to the mother?
- A. You should explain that fetal lie is where the fetus' presenting part is within the birth canal during labor, among other information about the other assessments.
- B. You should explain that fetal presentation is the relationship of the fetus's spine to the mother's spine, among other information about the other assessments.
- C. You should explain that fetal attitude is the relationship of the fetus' presenting part to the anterior, posterior, right or left side of the mother's pelvis, among other information about the other assessments.
- D. You should explain that fetal station is the level of the fetus' presenting part in relationship to the mother's ischial spines, among other information about the other assessments.
Correct Answer: D
Rationale: Fetal station refers to the level of the fetus's presenting part relative to the mother's ischial spines, measured in centimeters above or below the spines. This is the correct definition among the options provided.
The nurse on the antenatal unit is planning care for four clients. The nurse should assess which of the following clients first?
- A. A 29-year-old G3 P2 carrying twins, being treated for preterm labor at 29 weeks' gestation. She is receiving magnesium sulfate @ 2 g\hour. She has had no contractions for the past 2 hours and both twins appear stable, according to the nurse's shift report
- B. A 19-year-old 18 weeks' IUP who is now 12 hours post motor vehicle accident with bright red vaginal bleeding
- C. A G8 P4 Ab3 at 38 weeks' gestation hospitalized frequently during this pregnancy for placenta previa. Two days ago she was admitted with severe bright red vaginal bleeding that has tapered off now
- D. A 9-week IUP hospitalized for hyperemesis gravidarum who has not vomited for the last 12 hours
Correct Answer: B
Rationale: The 19-year-old with bright red vaginal bleeding post-accident at 18 weeks is at high risk for miscarriage or placental abruption, requiring immediate assessment. The other clients are stable or less acute.
The nurse is teaching a client with a new diagnosis of hypertension about lifestyle modifications. Which of the following instructions should be included? Select all that apply.
- A. Reduce sodium intake.
- B. Engage in regular aerobic exercise.
- C. Limit alcohol consumption.
- D. Quit smoking.
- E. Increase saturated fat intake.
Correct Answer: A, B, C, D
Rationale: Reducing sodium, exercising, limiting alcohol, and quitting smoking lower blood pressure. Saturated fats should be avoided.
A client was treated for a streptococcal throat infection 2 weeks ago. The client now has been diagnosed with acute poststreptococcal glomerulonephritis. The client asks the nurse how he could have prevented this condition. What should the nurse tell the client?
- A. See your physician for an early diagnosis and treatment of a sore throat.'
- B. As long as you do not have a fever, it is sufficient to gargle daily with an antibacterial mouthwash.'
- C. You may continue to utilize the previously prescribed antibiotics until they are gone.'
- D. Unscented bar soap may be used in showers.'
Correct Answer: A
Rationale: Early diagnosis and treatment of streptococcal infections prevent complications like glomerulonephritis. Mouthwash, leftover antibiotics, or soap use are not preventive measures.