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A nurse is teaching an in-service about manifestations of hypoglycemia to a group of newly licensed nurses. Which of the following should the nurse include in the teaching?
- A. Blurred vision
- B. Vomiting
- C. Kussmaul respirations
- D. Bradycardia
Correct Answer: A
Rationale: Corrected Rationale: Blurred vision is a common symptom of hypoglycemia and should be included in the teaching. Other manifestations like vomiting, Kussmaul respirations, and bradycardia are not typically associated with hypoglycemia. Vomiting is more commonly seen in conditions like food poisoning or gastrointestinal issues. Kussmaul respirations are deep and rapid respirations seen in metabolic acidosis, not hypoglycemia. Bradycardia is usually not a manifestation of hypoglycemia; tachycardia is more commonly associated with low blood sugar levels.
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A nurse is caring for a client who is receiving parenteral nutrition. Which of the following findings indicates the therapy is effective?
- A. Client has soft, formed bowel movements.
- B. Client's mucous membranes are pink.
- C. Client reports ability to complete ADLs.
- D. Client's blood glucose level is within the expected reference range.
Correct Answer: D
Rationale: The correct answer is D because having a blood glucose level within the expected reference range indicates that parenteral nutrition is effectively meeting the client's nutritional needs. Choices A, B, and C are incorrect because soft, formed bowel movements, pink mucous membranes, and the ability to complete activities of daily living do not directly reflect the effectiveness of parenteral nutrition therapy.
A nurse is caring for a 30-month-old toddler and is preparing a nutritional snack. Which of the following foods is appropriate for the nurse to offer the toddler?
- A. Plain popcorn
- B. Grapes
- C. Raw carrots
- D. Cheese
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is caring for four clients. The nurse should plan to administer total parenteral nutrition for which of the following clients?
- A. A client who is postoperative following a laminectomy and is receiving IV PCA
- B. A client who has dysphagia and does not recognize his family
- C. A client who has COPD and is going home with oxygen
- D. A client who has colon cancer and will undergo a hemicolectomy
Correct Answer: D
Rationale: Total parenteral nutrition (TPN) is essential for clients undergoing significant surgical procedures like a hemicolectomy to ensure they receive adequate nutrition when oral intake is not possible. Choices A, B, and C do not typically require TPN. Choice A is managing postoperative pain with IV PCA, choice B is likely to need alternative feeding methods due to dysphagia, and choice C is going home with oxygen for COPD management, which does not directly relate to the need for TPN.
During an initial visit with an older adult client living alone and having difficulty preparing meals, what should the home health nurse do first?
- A. Discuss nutritional requirements with the client.
- B. Refer the client to a senior citizen center.
- C. Arrange for a home-delivered meal program.
- D. Perform a nutrition screening.
Correct Answer: D
Rationale: Performing a nutrition screening is the most appropriate action for the nurse to take first. This allows the nurse to assess the client's current nutritional status and identify any specific needs. Discussing nutritional requirements with the client (Choice A) may be important but should come after the initial assessment. Referring the client to a senior citizen center (Choice B) or arranging for a home-delivered meal program (Choice C) are actions that may be considered later based on the findings of the nutrition screening.
A healthcare professional is reviewing the laboratory findings of a client who has heart failure. Which of the following findings indicates that the client is experiencing fluid volume excess?
- A. BUN 8 mg/dL
- B. Hgb 15 g/dL
- C. Creatinine 0.8 mg/dL
- D. Sodium 140 mEq/L
Correct Answer: A
Rationale: A BUN level of 8 mg/dL indicates fluid volume excess in a client with heart failure. BUN (Blood Urea Nitrogen) levels can be low in fluid overload due to hemodilution, a common occurrence in heart failure. High levels of BUN usually indicate dehydration or impaired renal function, which are not the case in fluid volume excess. Choices B, C, and D are within normal ranges and do not specifically indicate fluid volume excess.