Nokea
A nurse is caring for a patient with diabetes mellitus who is experiencing hyperglycemia. Which of the following interventions should the nurse implement? (Select all that apply)
- A. Administer insulin as prescribed
- B. Provide sugar-free fluids
- C. Encourage carbohydrate-rich snacks
- D. Monitor blood glucose levels regularly
- E. Assess for signs of diabetic ketoacidosis (DKA)
Correct Answer: A,B,D,E
Rationale: Insulin corrects hyperglycemia, sugar-free fluids prevent dehydration, monitoring tracks progress, and DKA assessment detects complications. Carbohydrate snacks worsen hyperglycemia.
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Right documentation includes the name, dosage, route, and time of administration. When should you sign your initials on the medication administration record?
- A. Immediately before the dose is given
- B. Immediately after the dose has been given
- C. Immediately before the dose is given, in the medication room
- D. Within one hour after administering the medication
Correct Answer: B
Rationale: Signing immediately after administration confirms the dose was given, ensuring accurate documentation. Signing before risks errors, and waiting an hour delays accuracy.
B.C. is a 14-yr-old boy who was brought to the ER after he had sustained flame burns. He had been wearing masquerade costume during Halloween celebration when his costume was set ablaze by the lighted candles in the party room. He extinguished the fire by rolling on the floor. On admission, resuscitation was commenced with intravenous fluids, antibiotics, and wound dressing. On examination he was found to be a young man, not pale, but febrile (body temperature, 37.8°C). He was tachypneic, RR 26 per min, with audible breath sounds bilaterally. Burn assessment revealed a total body surface area involved of 30%, with mixed-thickness burns sparing some patchy areas of the back and the right upper limb. B.C. anterior chest was affected.
For the first 24 hours after hospitalization, the nurse should primarily observe him for
- A. wound sepsis.
- B. complain of pain.
- C. dyspnea or stridor.
- D. initiate IV therapy.
Correct Answer: C
Rationale: Inhalation burns are usually present with facial burns, regardless of the depth; the immediate threat to life is asphyxia from irritation and edema of the respiratory passages and lungs.
Which of the following terms refers to soft-tissue injury caused by blunt force?
- A. contusion
- B. strain
- C. sprain
- D. dislocation
Correct Answer: A
Rationale: A contusion is a soft-tissue injury from blunt force, causing swelling and discoloration without breaking the skin. Strains and sprains involve ligaments or muscles, and dislocation affects joints. Physiological Adaptation
The physician has ordered IV replacement of potassium for a patient with severe hypokalemia.
The nurse would administer the IV potassium
- A. by rapid bolus.
- B. diluted in 100 cc over 1 hour.
- C. diluted in 10 cc over 10 minutes.
- D. IV push.
Correct Answer: B
Rationale: Potassium is diluted and infused slowly to prevent cardiac arrhythmias.
An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler's position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position (30°–45° elevation) promotes lung expansion and reduces the risk of airway obstruction or aspiration post-bronchoscopy. Prone (B) limits respiratory assessment, neck extension (C) risks airway obstruction, and supine (D) is less optimal for breathing.