Nokea
A man who has diabetes complains of hunger; is pale, shaky, and perspiring; and has cool skin. What is the most appropriate initial action for the nurse?
- A. Call the physician for orders
- B. Give the client cola to drink
- C. Have the client lie down
- D. Administer the next dose of insulin
Correct Answer: B
Rationale: Symptoms indicate hypoglycemia; giving cola provides quick glucose to raise blood sugar. Calling the physician, lying down, or giving insulin delays or worsens the situation.
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The nurse has a pre-op order to insert a Foley catheter in a male client. The catheter should be inserted:
- A. 1-2 inches
- B. 3-4 inches
- C. 5-6 inches
- D. 7-9 inches
Correct Answer: D
Rationale: In males, a Foley catheter is inserted 7-9 inches to reach the bladder, ensuring proper placement without trauma.
The nurse observes a staff member caring for a client with a left unilateral mastectomy. The nurse would intervene if she notices the staff member is
- A. Advising client to restrict sodium intake
- B. Taking the blood pressure in the left arm
- C. Elevating her left arm above heart level
- D. Compressing the drainage device
Correct Answer: B
Rationale: Taking the blood pressure in the left arm. Clients who have had a unilateral mastectomy should not have their blood pressure measured on the affected side. This helps avoid the possibility of lymphedema post-operatively and in the future.
The nurse assesses several post partum women in the clinic. Which of the following women is at highest risk for puerperal infection?
- A. 12 hours post partum, temperature of 100.4 degrees Fahrenheit since delivery
- B. 2 days post partum, temperature of 101.2 degrees Fahrenheit this morning
- C. 3 days post partum, temperature of 101.2 degrees Fahrenheit the past 2 days
- D. 4 days post partum, temperature of 100 degrees Fahrenheit since delivery
Correct Answer: C
Rationale: A temperature of 100.4 degrees Fahrenheit or higher on 2 successive days, not counting the first 24 hours after birth, indicates a post partum infection.
A client presents with confusion, mood lability, impaired communication, and lethargy.
The nurse should question which of the following orders?
- A. Dexamethasone suppression Test .
- B. Thyroid studies.
- C. Drug toxicology screen.
- D. Trendelenburg Test .
Correct Answer: D
Rationale: Strategy: Think about each Test . (1) may be ordered to determine the presence of major depression (2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made (3) may be ordered to see if the client's symptoms are caused by excessive use of medications or alcohol (4) correct-Test is used with a client who may have varicose veins, no relationship to the symptoms described in this situation
A husband and wife meet at the mental health clinic to make an appointment for family therapy. Suddenly, the wife begins to sob loudly. As the nurse approaches, the husband says, 'I guess we just don't get along.' Which of the following responses by the nurse is MOST appropriate?
- A. Your wife seems to be upset by the situation.
- B. Perhaps you should both go home now.
- C. Try to think about what precipitated her crying.
- D. The situation is difficult for both of you.
Correct Answer: D
Rationale: Acknowledging the emotional impact on both spouses fosters therapeutic communication without judgment. Options A, B, and C are less effective: A focuses only on the wife, B dismisses the situation, and C may provoke defensiveness.