Nokea
A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL. Which of the following findings should the nurse identify as an indication of metabolic acidosis?
- A. Tingling of the fingers
- B. Positive Trousseau's sign
- C. Increased respiratory rate
- D. Dizziness upon standing
- E. Hypotension
- F. Muscle weakness
- G. Dry mouth
Correct Answer: C
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for acidosis in diabetic ketoacidosis.
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A nurse in a long-term care facility is providing care for a client who has Alzheimer's disease and is agitated. Which of the following interventions should the nurse implement?
- A. Administer a prescribed oral dose of trazodone to the client.
- B. Encourage the client to ambulate with a staff member.
- C. Isolate the client in their room.
- D. Apply bilateral wrist restraints to the client.
Correct Answer: A
Rationale: Trazodone, if prescribed, can calm agitation in Alzheimer's safely. Ambulation may help but isn't immediate, isolation can worsen agitation, and restraints are a last resort.
A nurse is contributing to the plan of care for a client who is starting bowel training for the management of fecal incontinence. Which of the following interventions should the nurse recommend?
- A. Limit the client's physical activity until bowel continence is achieved.
- B. Assist the client to the restroom 30 min after meals.
- C. Instruct the client to limit their intake of high-fiber foods.
- D. Limit the client's fluid intake to 1500 mL/day
Correct Answer: B
Rationale: Bowel training aims to establish a regular pattern for defecation, particularly for clients with fecal incontinence, by leveraging the gastrocolic reflex, which increases intestinal motility after meals. Option A is incorrect because limiting physical activity does not promote bowel regularity and may worsen incontinence by reducing muscle tone. Option B is correct as assisting the client to the restroom 30 minutes after meals takes advantage of this reflex, encouraging predictable bowel movements and enhancing control over time. Option C is wrong since high-fiber foods aid bowel regularity by adding bulk to stool, which helps with continence, not hinders it. Option D is also incorrect adequate fluid intake (not restriction to 1500 mL/day) supports healthy stool consistency and prevents constipation, a key factor in incontinence management. Assisting post-meal aligns with physiological principles and patient-centered care, making it the best intervention for effective bowel training.
A nurse is caring for a client who is receiving intermittent bolus enteral feedings through a jejunostomy tube. Which of the following actions should the nurse take?
- A. Elevate the head of the client's bed for 1 hr. after the feeding.
- B. Administer the feeding solution at a cold temperature.
- C. Rotate the jejunostomy tube once per day.
- D. Flush the tube with 90 mL of sterile water before and after the feeding.
Correct Answer: A
Rationale: Elevating the head for 1 hour post-feeding prevents aspiration, a key concern with jejunostomy feedings. Cold solutions, rotation, and excessive flushing aren't standard.
A nurse is reinforcing teaching with a client who has a grade 2 ankle sprain. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will apply heat to my affected ankle to decrease swelling.
- B. I can bear full weight on my affected ankle.
- C. I can dangle my affected ankle from the edge of the bed.
- D. I will wrap my affected ankle with an elastic bandage.
Correct Answer: D
Rationale: Wrapping with an elastic bandage provides compression to reduce swelling in a grade 2 sprain. Heat increases swelling, full weight-bearing is premature, and dangling worsens edema.
A nurse is reinforcing teaching with a client about breast self-examinations. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform breast exams the day my period begins.
- B. I will perform breast exams every other month.
- C. It is common for the skin on my breasts to dimple.
- D. It is common for one breast to be larger than the other.
Correct Answer: D
Rationale: It's normal for one breast to be slightly larger than the other, and this statement reflects an accurate understanding of breast anatomy. Dimpling can be a sign of concern, and exams should be done monthly, about a week after the period starts, not on the first day or every other month.