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A nurse is assisting with the care of a client who has hypocalcemia. For which of the following signs should the nurse monitor?
- A. Kernig's sign.
- B. Brudzinski's sign.
- C. Chvostek's sign.
- D. Cullen's sign.
Correct Answer: C
Rationale: Chvostek's sign, facial muscle twitching when tapping the facial nerve, is a clinical sign of hypocalcemia.
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A nurse is caring for a client who is postoperative following a right total hip arthroplasty. In which of the following positions should the nurse place the client's right leg?
- A. Abduction.
- B. Internal rotation.
- C. External rotation.
- D. Adduction.
Correct Answer: A
Rationale: Abduction prevents hip dislocation by keeping the leg away from the midline, maintaining joint stability post-arthroplasty.
A nurse is reinforcing teaching with a female client about preventing urinary tract infections (UTIs). Which of the following instructions should the nurse include?
- A. Drink 16 oz of cranberry juice each day.
- B. Use an over-the-counter douche product after intercourse.
- C. Wait to void until the bladder feels full.
- D. Wear underwear made from nylon.
Correct Answer: A
Rationale: Drinking 16 oz of cranberry juice daily helps prevent UTIs by inhibiting bacterial adhesion to the urinary tract lining.
A nurse is preparing to administer diphenhydramine 30 mg IM stat to a client who is having an allergic reaction. Available is diphenhydramine 50 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. (Do not use a trailing zero))
Correct Answer: 0.6 mL
Rationale: 30 mg ÷ 50 mg/mL = 0.6 mL. The nurse should administer 0.6 mL per dose.
A nurse is reinforcing teaching with a client who has type 1 diabetes mellitus. Which of the following statements from the client indicates to the nurse the teaching is effective?
- A. I will freeze unopened insulin vials.
- B. I should increase my insulin when I exercise.
- C. I should inject the insulin into my abdominal area.
- D. I will shake the insulin vial vigorously to mix.
Correct Answer: C
Rationale: Injecting insulin into the abdominal area ensures consistent absorption, a recommended site for effective insulin administration.
An adult client newly diagnosed with type 2 diabetes mellitus asks a nurse to explain how he developed the condition. Which of the following responses should the nurse make?
- A. Your body will continue producing too much insulin without medicine to counteract it.
- B. Your body doesn't process glucose well.
- C. Your body's hemoglobin is not binding to the sugar you consume.
- D. Your body's immune system has destroyed cells in your pancreas.
Correct Answer: B
Rationale: Type 2 diabetes involves insulin resistance, where the body cannot process glucose effectively, leading to elevated blood glucose levels.