Nokea
A nurse is reinforcing teaching about the manifestations of hyperglycemia with a client who has diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching?
- A. My breath may have a fruity odor.
- B. I will be more thirsty than usual.
- C. My appetite will be decreased.
- D. I might experience blurry vision at times.
Correct Answer: B
Rationale: Increased thirst (polydipsia) is a classic hyperglycemia symptom due to dehydration from glucose excretion.
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A nurse is assisting with teaching a client about water-soluble vitamins. Which of the following vitamins should the nurse include?
- A. Vitamin E
- B. Vitamin A
- C. Vitamin C
- D. Vitamin D
Correct Answer: C
Rationale: Vitamin C is water-soluble, requiring regular intake as it's not stored in the body.
A charge nurse in a long-term care facility will be implementing a new protocol to meet the Joint Commission's National Safety Goal of preventing health care-associated pressure ulcers. When informing the staff nurses about the new standard, the nurse should emphasize that which of the following actions is the priority?
- A. Identify the clients at greatest risk for development of pressure ulcers.
- B. Use a barrier cream when performing perineal care.
- C. Turn and position each client every 2 hr.
- D. Supervise clients to ensure adequate nutritional intake.
Correct Answer: A
Rationale: Identifying at-risk clients prioritizes preventive efforts for pressure ulcer management.
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse take prior to administering the tube feeding?
- A. Assist the client to low Fowler's position.
- B. Test the pH of gastric aspirate.
- C. Discard any residual gastric contents.
- D. Warm the feeding solution to body temperature.
Correct Answer: B
Rationale: Testing gastric aspirate pH confirms NG tube placement in the stomach (pH 1-4).
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Dry mucous membranes
- C. Diaphoresis
- D. Polyuria
Correct Answer: C
Rationale: Diaphoresis (sweating) is a classic sign of hypoglycemia due to sympathetic nervous system activation, unlike fruity breath (hyperglycemia) or polyuria (hyperglycemia).
A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?
- A. BUN
- B. Potassium
- C. RBC count
- D. WBC count
Correct Answer: D
Rationale: Elevated WBC count, especially neutrophils, indicates infection response in a pressure ulcer.