Nokea
A nurse is monitoring a client who has diabetes mellitus and a glucose level of 384 mg/dL (74 to 106 mg/dL). Which of the following findings should the nurse identify as an indication of metabolic acidosis?
- A. Positive Trousseau's sign
- B. Dizziness upon standing
- C. Tingling of the fingers
- D. Increased respiratory rate
Correct Answer: D
Rationale: Increased respiratory rate (Kussmaul breathing) compensates for metabolic acidosis in hyperglycemia, as the body tries to eliminate excess acid.
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A nurse is reinforcing discharge teaching with a client who has a new permanent pacemaker. Which of the following statements by the client indicates an understanding of the teaching?
- A. I'll make sure I stay away from microwave ovens.
- B. I should have an MRI, rather than a CAT scan, if necessary.
- C. I'll hold my cell phone against the ear on the opposite side of my body.
- D. I shouldn't travel by plane because of airport security.
Correct Answer: C
Rationale: Holding a cell phone on the opposite side minimizes electromagnetic interference with the pacemaker. Microwaves and airport security are generally safe, and MRIs are contraindicated due to the magnetic field.
NURSES’ NOTES
1000:
Client reports that over the past 2 months they have noticed multiple changes with their body. They have a decrease in activity tolerance, feel tired all the time, and have had difficulty remembering things. The client also states they bruise easily, are experiencing constipation, and they no longer tolerate the cold like they used to.
Client states they are concerned about exposure to seasonal viruses from other patrons.
Reports that they are currently experiencing a headache with a pain of 3 on a scale of 0 to 10.
Actions to Take
• Limit caffeine intake.
• Observe the need to administer sumatriptan.
• Withhold lithium.
Potential Condition
• Influenza
• Lithium toxicity
• Migraine
Parameters to Monitor
• Flashing lights
• Blurred vision
• Chest pain
A nurse in a provider's office is caring for a client who reports changes in their health over the past 2 months. What condition is the client most likely experiencing?
- A. Influenza
- B. Lithium toxicity
- C. Migraine
- D. Hypothyroidism
Correct Answer: D, A
Rationale: Symptoms like decreased activity tolerance, fatigue, memory issues, bruising, constipation, and cold intolerance over 2 months suggest hypothyroidism thyroid hormone deficiency slows metabolism, causing systemic effects. Influenza is acute, with fever and respiratory symptoms, not chronic fatigue or bruising. Lithium toxicity includes tremor or confusion, but not cold intolerance or constipation as primary signs. Migraine causes headaches (here, 3/10), but not multisystem changes like bruising or memory loss. Hypothyroidism fits the gradual onset and constellation fatigue from low energy, memory fog from cerebral hypoperfusion, and constipation from sluggish gut motility requiring thyroid function tests (e.g., TSH), making it the most likely condition.
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 who is taking enoxaparin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will use ibuprofen when I have a headache.
- B. I will use an electric razor for shaving
- C. I will avoid the use of stool softeners.
- D. I will massage the site after each injection.
Correct Answer: B
Rationale: Using an electric razor reduces bleeding risk with enoxaparin, an anticoagulant. Ibuprofen increases bleeding, stool softeners may be needed, and massaging injection sites is contraindicated.
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 prevents aspiration, essential for jejunostomy feeding safety. Cold solutions, rotation, and large flushes are not recommended.