Nokea
A client with type 1 diabetes mellitus is admitted with symptoms of hyperglycemia. Which laboratory finding should the nurse expect?
- A. Blood glucose of 90 mg/dL.
- B. Serum pH of 7.45.
- C. Ketones present in urine.
- D. Serum potassium of 5.5 mEq/L.
Correct Answer: C
Rationale: Hyperglycemia in type 1 diabetes often leads to diabetic ketoacidosis, with ketones in the urine due to fat metabolism, a key finding to monitor.
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The nurse instills 5 mL of normal saline before suctioning a client's tracheostomy tube. The instillation is effective when:
- A. The secretions are thinned.
- B. The client coughs.
- C. There is minimal friction when the catheter is passed into the tracheostomy tube.
- D. There is humidification for the respiratory tract.
Correct Answer: A
Rationale: Instilling normal saline thins secretions, facilitating effective suctioning of the tracheostomy tube.
A nurse is relieving the triage nurse in the labor and delivery unit who is going to lunch. The report indicates that there are three clients having their vital signs assessed and a fourth client is on her way to the unit from the emergency department. In which order of priority should the nurse manage these clients?
- A. The client with clear vesicles and brown vaginal discharge at 16 weeks' gestation.
- B. The client with right lower quadrant pain at 10 weeks' gestation.
- C. The client who is at term and has had no fetal movement for 2 days.
- D. The client from the emergency department at term and screaming loudly because of labor contractions.
Correct Answer: C,D,A,B
Rationale: The client with no fetal movement at term is the highest priority due to the risk of fetal distress. The client in active labor requires immediate attention. Vesicles and discharge suggest possible infection, and right lower quadrant pain may indicate ectopic pregnancy, both serious but less urgent.
A client with a history of type 2 diabetes mellitus is prescribed liraglutide (Victoza). The nurse should monitor the client for which of the following side effects?
- A. Hypoglycemia.
- B. Pancreatitis.
- C. Hypertension.
- D. Weight gain.
Correct Answer: B
Rationale: Liraglutide can cause pancreatitis, a serious side effect requiring monitoring for symptoms like abdominal pain.
A client with a history of chronic kidney disease is prescribed darbepoetin alfa (Aranesp). The nurse should monitor the client for which of the following side effects?
- A. Hypotension.
- B. Hypertension.
- C. Hypoglycemia.
- D. Weight loss.
Correct Answer: B
Rationale: Darbepoetin alfa can cause hypertension due to increased red blood cell production, requiring monitoring.
A client receiving a blood transfusion begins to have chills and headache within the first 15 minutes of the transfusion. The nurse should first:
- A. Administer acetaminophen.
- B. Take the client's blood pressure.
- C. Discontinue the transfusion.
- D. Check the infusion rate of the blood.
Correct Answer: C
Rationale: Chills and headache suggest a transfusion reaction, requiring immediate discontinuation of the transfusion to prevent further complications.