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A patient with type 1 diabetes mellitus is admitted to the hospital with diabetic ketoacidosis (DKA). What is the priority nursing action?
- A. Administer regular insulin intravenously.
- B. Give oral hypoglycemic agents.
- C. Administer sodium bicarbonate.
- D. Provide a high-calorie diet.
Correct Answer: A
Rationale: The correct answer is A: Administer regular insulin intravenously. In DKA, the priority is to lower blood glucose levels and correct acidosis. Regular insulin intravenously is the fastest way to reduce blood glucose levels. Oral hypoglycemic agents (B) are not effective in DKA. Sodium bicarbonate (C) is not routinely recommended in DKA as it may worsen acidosis. Providing a high-calorie diet (D) is not appropriate as the focus should be on treating the underlying condition first.
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A patient with systemic lupus erythematosus (SLE) is prescribed hydroxychloroquine. What is the most important instruction the nurse should give?
- A. Report any vision changes immediately.
- B. Take the medication with milk.
- C. Avoid high-fat foods.
- D. Increase intake of green leafy vegetables.
Correct Answer: A
Rationale: The correct answer is A: Report any vision changes immediately. This is crucial because hydroxychloroquine can cause retinal toxicity, which may lead to irreversible vision loss. Monitoring for vision changes allows for early detection and intervention. Choice B is incorrect as hydroxychloroquine is typically taken with food or milk to reduce gastrointestinal side effects. Choice C is irrelevant as there is no specific dietary restriction for hydroxychloroquine. Choice D is also incorrect as there is no evidence to support increasing green leafy vegetable intake in relation to hydroxychloroquine therapy.
A client with liver cirrhosis is prescribed lactulose. What is the purpose of this medication?
- A. To lower blood sugar levels
- B. To reduce ammonia levels
- C. To treat liver inflammation
- D. To improve bile flow
Correct Answer: B
Rationale: Rationale: Lactulose is prescribed for liver cirrhosis to reduce ammonia levels. It works by promoting the excretion of ammonia in the stool, preventing its accumulation in the bloodstream. This helps prevent hepatic encephalopathy, a serious complication of cirrhosis. Other choices are incorrect because lactulose does not directly affect blood sugar levels, liver inflammation, or bile flow in the context of liver cirrhosis.
What instruction should a patient with a history of hypertension be provided when being discharged with a prescription for a thiazide diuretic?
- A. Avoid foods high in potassium.
- B. Take the medication at bedtime.
- C. Monitor weight daily.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: C
Rationale: Rationale:
C is correct because thiazide diuretics can cause fluid retention, leading to weight gain, which may indicate worsening heart failure or hypertension. Daily weight monitoring helps detect fluid retention early, enabling timely intervention.
Summary:
A: Incorrect. Thiazide diuretics can cause potassium loss, so avoiding potassium-rich foods is not necessary.
B: Incorrect. Taking the medication in the morning is preferred to prevent nocturia and sleep disturbances.
D: Incorrect. Fluid intake should not be limited unless advised by a healthcare provider to prevent dehydration.
A patient with a diagnosis of deep vein thrombosis (DVT) is receiving heparin therapy. Which laboratory test should the nurse monitor to evaluate the effectiveness of the heparin therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. Bleeding time
- D. Platelet count
Correct Answer: B
Rationale: The correct answer is B: Partial thromboplastin time (PTT). PTT is used to monitor the effectiveness of heparin therapy because heparin primarily affects the intrinsic pathway of the coagulation cascade, which is reflected in the PTT results. Monitoring PTT helps to ensure that the patient's blood is within the therapeutic range for anticoagulation.
A: Prothrombin time (PT) is used to monitor warfarin therapy, which affects the extrinsic pathway of the coagulation cascade.
C: Bleeding time is not typically used to monitor heparin therapy effectiveness.
D: Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not directly reflect the effectiveness of heparin therapy in preventing or treating DVT.
A client with a new diagnosis of myasthenia gravis is prescribed pyridostigmine (Mestinon). Which instruction should the nurse include in the client's teaching?
- A. Take the medication with food to prevent gastrointestinal upset.
- B. Take the medication 30 minutes before meals.
- C. Avoid dairy products while taking this medication.
- D. Take the medication at bedtime.
Correct Answer: B
Rationale: The correct answer is B: Take the medication 30 minutes before meals. Pyridostigmine is a cholinesterase inhibitor used to treat myasthenia gravis by improving muscle strength. Taking it before meals helps optimize its effects when muscle strength is needed the most during eating. Taking it with food (A) may delay absorption. Avoiding dairy products (C) is not necessary with pyridostigmine. Taking the medication at bedtime (D) may not be optimal for addressing muscle weakness during meal times.