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A client with type 1 diabetes mellitus is experiencing nausea and vomiting. What advice should the nurse give regarding insulin administration?
- A. Skip your insulin dose until you can eat.'
- B. Take your insulin as prescribed, but monitor your blood glucose closely.'
- C. Reduce your insulin dose by half.'
- D. Only take your long-acting insulin.'
Correct Answer: B
Rationale: The correct answer is B because skipping insulin can lead to dangerous complications like diabetic ketoacidosis. Taking insulin as prescribed ensures blood glucose control, preventing hyperglycemia. Monitoring blood glucose closely helps adjust doses accordingly. Choice A is incorrect as skipping insulin can be life-threatening. Choice C is incorrect as reducing insulin without proper monitoring can lead to unstable glucose levels. Choice D is incorrect as both long-acting and short-acting insulin are essential for managing type 1 diabetes.
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The patient has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan?
- A. Maintain the patient on bed rest.
- B. Auscultate lung sounds every 4 hours.
- C. Monitor for Trousseau's and Chvostek's signs.
- D. Encourage fluid intake up to 4000 mL every day.
Correct Answer: D
Rationale: The correct answer is D: Encourage fluid intake up to 4000 mL every day. High calcium levels can lead to dehydration, so encouraging fluid intake helps prevent this complication. Increased fluid intake also promotes calcium excretion through urine. Bed rest (A) is not directly related to managing high calcium levels. Auscultating lung sounds (B) every 4 hours is more relevant for respiratory issues. Monitoring for Trousseau's and Chvostek's signs (C) is associated with low calcium levels, not high levels.
A patient who is diagnosed with cervical cancer that is classified as Tis, N0, M0 asks the nurse what the letters and numbers mean. Which response by the nurse is most appropriate?
- A. The cancer involves only the cervix.
- B. The cancer cells closely resemble normal cells.
- C. Further testing is necessary to determine the spread of the cancer.
- D. Determining the original site of the cervical cancer is challenging.
Correct Answer: A
Rationale: Step-by-step rationale for why answer A is correct:
1. Tis refers to carcinoma in situ, meaning the cancer is limited to the surface layer of cells in the cervix.
2. N0 indicates no regional lymph node involvement.
3. M0 indicates no distant metastasis.
4. Therefore, the cancer is localized only to the cervix, making answer A correct.
Summary:
B: Incorrect - Does not address the staging information provided in Tis, N0, M0.
C: Incorrect - The staging information is already provided, and further testing may not be necessary at this stage.
D: Incorrect - Staging information does not indicate difficulty in determining the original site of the cancer.
What side effect should be monitored for in a patient with chronic heart failure taking spironolactone?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. It works by blocking the aldosterone receptor, leading to potassium retention and potential hyperkalemia. Monitoring potassium levels is crucial as hyperkalemia can increase the risk of arrhythmias and other cardiac complications in heart failure patients.
A: Hypokalemia is incorrect because spironolactone typically causes potassium retention.
C: Hyponatremia and D: Hypernatremia are incorrect as spironolactone does not directly affect sodium levels.
In summary, monitoring for hyperkalemia is essential in patients with heart failure taking spironolactone to prevent adverse cardiac events.
A patient with a diagnosis of peptic ulcer disease is prescribed omeprazole. When should the patient take this medication for optimal effectiveness?
- A. With meals
- B. At bedtime
- C. Before meals
- D. After meals
Correct Answer: C
Rationale: The correct answer is C: Before meals. Omeprazole is a proton pump inhibitor that works by reducing stomach acid production. Taking it before meals allows the medication to be most effective in inhibiting the proton pumps before they are stimulated by food intake. This timing optimizes the drug's ability to reduce acid secretion during the digestion process.
Choice A (With meals) is incorrect because taking omeprazole with meals may reduce its effectiveness as it will not have enough time to inhibit acid production before food intake. Choice B (At bedtime) is also incorrect as omeprazole works best when taken before meals to prevent acid production. Choice D (After meals) is incorrect because waiting until after meals to take omeprazole means that acid production has already been stimulated by the food consumed, reducing the drug's effectiveness in inhibiting acid secretion.
The healthcare professional is caring for a client with heart failure who is receiving digoxin (Lanoxin). Which assessment finding requires immediate intervention?
- A. Heart rate of 58 beats per minute.
- B. Nausea and vomiting.
- C. Blood pressure of 130/80 mm Hg.
- D. Shortness of breath.
Correct Answer: B
Rationale: The correct answer is B: Nausea and vomiting. This finding requires immediate intervention because digoxin toxicity can present with gastrointestinal symptoms like nausea and vomiting. This can indicate an overdose of digoxin, which can be life-threatening. Prompt action is necessary to prevent further complications.
A: Heart rate of 58 beats per minute is within the therapeutic range for digoxin and does not require immediate intervention.
C: Blood pressure of 130/80 mm Hg is also within normal limits and does not indicate an urgent issue.
D: Shortness of breath can be a symptom of heart failure but is not a direct indication of digoxin toxicity requiring immediate intervention.