Nokea
A nurse is obtaining a 2-hr postprandial blood glucose from a client. Which of the following actions should the nurse take?
- A. Puncture the finger while still damp with antiseptic solution.
- B. Smear the blood onto the reagent strip.
- C. Hold the finger above the heart prior to puncture.
- D. Select the lateral side of the finger for puncture.
Correct Answer: D
Rationale: The correct answer is D: Select the lateral side of the finger for puncture. This choice is correct because the lateral side of the finger has fewer nerve endings, making it less painful for the client. It also minimizes the risk of injury to the client and provides an adequate blood sample for testing.
Explanation for other choices:
A: Puncturing the finger while still damp with antiseptic solution can dilute the blood sample, leading to inaccurate results.
B: Smearing the blood onto the reagent strip can cause contamination and inaccurate readings.
C: Holding the finger above the heart prior to puncture can lead to increased blood flow and affect the accuracy of the blood glucose reading.
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A nurse is assessing a client who is at 6 weeks of gestation and adheres to a vegan diet. Which of the following questions should the nurse ask to assess the client’s dietary intake?
- A. How much protein do you eat in a day?
- B. Are you taking a Vitamin C supplement?
- C. Have you considered eating shellfish?
- D. When was the last time you ate meat?
Correct Answer: A
Rationale: The correct answer is A: How much protein do you eat in a day? This question is important because a vegan diet may lack sufficient protein, which is crucial for fetal development during pregnancy. Protein intake should be monitored to ensure the client is meeting their nutritional needs.
Incorrect choices:
B: Are you taking a Vitamin C supplement? - While Vitamin C is important, assessing protein intake is more critical for a vegan diet.
C: Have you considered eating shellfish? - Shellfish is not suitable for a vegan diet.
D: When was the last time you ate meat? - Irrelevant for a vegan client.
A nurse is teaching a client who has pregestational type 1 diabetes mellitus about management during pregnancy. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will need to increase my insulin doses during the first trimester.
- B. I should engage in moderate exercise for 30 minutes if my blood glucose is 250 or greater.
- C. I will continue taking my insulin if I experience nausea and vomiting.
- D. I will ensure that my bedtime snack is high in refined sugar.
Correct Answer: C
Rationale: Correct Answer: C - "I will continue taking my insulin if I experience nausea and vomiting."
Rationale: Nausea and vomiting can lead to decreased food intake, which may cause a drop in blood glucose levels. Continuing to take insulin as prescribed is crucial to prevent hypoglycemia and maintain stable blood glucose levels for both the mother and the baby. This demonstrates the client's understanding of the importance of insulin therapy during pregnancy.
Summary of other choices:
A: Increasing insulin doses during the first trimester is not recommended without healthcare provider guidance as insulin needs may vary.
B: Exercising with blood glucose levels of 250 or greater can be dangerous and may lead to further hyperglycemia.
D: Consuming a bedtime snack high in refined sugar can cause blood glucose spikes, which is not recommended for diabetes management during pregnancy.
A nurse is assessing a newborn who was born at 26 weeks of gestation using the New Ballard Score. Which of the following findings should the nurse expect?
- A. Minimal arm recoil
- B. Popliteal angle of 90°
- C. Creases over the entire foot sole
- D. Raised areolas with 3 to 4 mm buds
Correct Answer: A
Rationale: The correct answer is A. At 26 weeks of gestation, newborns are expected to have minimal arm recoil based on the New Ballard Score, as their muscle tone is typically low. This indicates immaturity and aligns with the developmental stage of a premature infant. The other choices are incorrect because: B: A popliteal angle of 90° is more indicative of a term infant. C: Creases over the entire foot sole are also seen in term infants, not premature infants. D: Raised areolas with 3 to 4 mm buds are associated with breast development in term infants, not preterm infants.
A nurse is assessing a client who is postpartum and has idiopathic thrombocytopenia purpura (ITP). Which of the following findings should the nurse expect?
- A. Decreased platelet count
- B. Increased erythrocyte sedimentation rate (ESR)
- C. Decreased megakaryocytes
- D. Increased WBC
Correct Answer: A
Rationale: The correct answer is A: Decreased platelet count. In ITP, there is a decrease in the number of platelets, leading to an increased risk of bleeding. Platelets are essential for blood clotting, so a decreased count can result in easy bruising, petechiae, and prolonged bleeding. The other choices are incorrect because in ITP, there is no significant increase in ESR, decrease in megakaryocytes (which are platelet precursors), or increase in WBC count. By understanding the pathophysiology of ITP and its effects on platelets, we can confidently select choice A as the expected finding in this scenario.
A nurse is assessing a newborn who has neonatal abstinence syndrome. Which of the following findings should the nurse expect?
- A. Diminished deep tendon reflexes
- B. Excessive crying
- C. Decreased muscle tone
- D. Absent Moro reflex
Correct Answer: B
Rationale: The correct answer is B: Excessive crying. Neonatal abstinence syndrome is characterized by withdrawal symptoms in newborns due to exposure to drugs in utero. Excessive crying is a common manifestation of this syndrome as the newborn experiences discomfort and agitation. Diminished deep tendon reflexes (A), decreased muscle tone (C), and absent Moro reflex (D) are not typically associated with neonatal abstinence syndrome. These findings may be seen in other conditions, but not specifically in newborns with this syndrome.