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A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?
- A. Assess the client's oxygen saturation level.
- B. Determine the client's current glucose level
- C. Give the client one-half cup of fruit juice.
- D. Give the client skim milk and crackers.
Correct Answer: B
Rationale: Checking glucose confirms hypoglycemia, indicated by symptoms, guiding appropriate treatment.
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A client is scheduled for a scleral buckling procedure after previously having multiple laser coagulation procedures done for retinal tears. Which Information about the immediate postoperative period should the nurse provide this client?
- A. Report reoccurring visual signs of retinal detachment.
- B. Maintain the head in one postoperative position.
- C. Watch for signs of infection in the surgical eye.
- D. Ambulate to the bathroom with assistance.
Correct Answer: A
Rationale: Reporting signs of retinal detachment is critical to ensure the success of the scleral buckling procedure.
A client recovering from cardiac surgery experiences a dysrhythmia, noted on the telemetry monitor. Which assessment finding is most likely to have contributed to the development of the dysrhythmia?
- A. Calcium level 7.2 mg/dL (1.8 mmol/L).
- B. Potassium level 3.8 mg/dl. (3.8 mmol)
- C. Sodium level 140 mEq/L (140mmol/L).
- D. Oxygen saturation level 97%.
Correct Answer: A
Rationale: Hypocalcemia (low calcium) can cause cardiac dysrhythmias, such as prolonged QT intervals, unlike normal potassium, sodium, or oxygen levels.
A client with coronary artery disease is hospitalized with unstable angina. To reduce cardiac workload, which intervention should the nurse include in the client's plan of care?
- A. Encourage active range of motion exercises.
- B. Assist with ambulation in the hallway.
- C. Provide a bedside commode for toileting.
- D. Teach to sleep in a side lying position.
Correct Answer: C
Rationale: A bedside commode minimizes physical exertion, reducing cardiac workload in unstable angina.
History and Physical
Nurses' Notes
Orders
Imaging Studies
The client is a young male who appears to be 25 to 30 years old. He was found unconscious on a sidewalk by a jogger who was passing by. The jogger called an ambulance, and the emergency medical technicians (EMTS) transported the client to the hospital. The client is arousable but unable to say what his name is or what happened to him. A STAT head computed tomography (CT) scan in the emergency department showed no abnormalities, so the client will be admitted to the medical floor for observation and further tests.
The healthcare provider comes to the bedside following the seizure and prescribes phenytoin. The nurse administers the phenytoin as prescribed. Which possible side effect(s) of phenytoin should the nurse assess for after administration? Select all that apply.
- A. Vomiting
- B. Altered blood coagulation
- C. Visual disturbances
- D. Drowsiness
- E. Aphasia
- F. Ataxia
Correct Answer: B,C,D,F
Rationale: Phenytoin may cause altered coagulation, visual disturbances, drowsiness, and ataxia, affecting safety and monitoring needs.
The nurse is developing a teaching handout for female clients who return to the clinic for recurring urinary tract infections (UTI). Which client has the greatest risk for developing a UTI?
- A. An adolescent who drinks a minimum of four diet drinks daily.
- B. A client who is too busy at work to void when the urge occurs.
- C. A multipara who had pyelonephritis during her last pregnancy.
- D. An older adult who is usually incontinent of urine during the night
Correct Answer: C
Rationale: A history of pyelonephritis increases UTI risk due to prior severe urinary infection, unlike dietary habits or incontinence.