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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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What side effect should be monitored for in a patient with chronic heart failure taking spironolactone?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypernatremia
Correct Answer: B
Rationale: The correct answer is B: Hyperkalemia. Spironolactone is a potassium-sparing diuretic commonly used in patients with heart failure. It works by blocking the aldosterone receptor, leading to potassium retention and potential hyperkalemia. Monitoring potassium levels is crucial as hyperkalemia can increase the risk of arrhythmias and other cardiac complications in heart failure patients.
A: Hypokalemia is incorrect because spironolactone typically causes potassium retention.
C: Hyponatremia and D: Hypernatremia are incorrect as spironolactone does not directly affect sodium levels.
In summary, monitoring for hyperkalemia is essential in patients with heart failure taking spironolactone to prevent adverse cardiac events.
In a client with liver cirrhosis experiencing confusion and disorientation, what condition is most likely causing these symptoms?
- A. Hepatic encephalopathy
- B. Hypoglycemia
- C. Electrolyte imbalance
- D. Dehydration
Correct Answer: A
Rationale: The correct answer is A: Hepatic encephalopathy. In liver cirrhosis, the liver's ability to detoxify ammonia is impaired, leading to elevated ammonia levels in the blood. This excess ammonia crosses the blood-brain barrier, causing neurological symptoms like confusion and disorientation. Hypoglycemia (B), electrolyte imbalance (C), and dehydration (D) can also contribute to altered mental status, but in a cirrhotic patient, hepatic encephalopathy is the most likely cause due to impaired ammonia metabolism.
The sister of a patient diagnosed with BRCA gene¢â‚¬"related breast cancer asks the nurse, 'Do you think I should be tested for the gene?' Which response by the nurse is most appropriate?
- A. In most cases, breast cancer is not caused by the BRCA gene.
- B. It depends on how you will feel if the test is positive for the BRCA gene.
- C. There are many things to consider before deciding to have genetic testing.
- D. You should decide first whether you are willing to have a bilateral mastectomy.
Correct Answer: C
Rationale: The correct answer is C because genetic testing for the BRCA gene involves complex considerations beyond just the test results. By stating that there are many things to consider before deciding to have genetic testing, the nurse acknowledges the importance of discussing the potential implications of the test result, such as emotional, social, and medical factors. This response promotes informed decision-making and empowers the patient to make a well-considered choice.
Choices A, B, and D are incorrect:
A: This statement is inaccurate as a significant proportion of breast cancers are indeed linked to the BRCA gene mutations.
B: This response oversimplifies the decision-making process by focusing solely on emotional aspects, neglecting other critical factors that should be considered before genetic testing.
D: This option is not appropriate as it suggests a specific treatment option (bilateral mastectomy) without addressing the broader aspects of genetic testing and decision-making.
A patient with rheumatoid arthritis is prescribed methotrexate. What should the nurse include in the patient teaching?
- A. Take folic acid supplements as prescribed.
- B. Avoid alcohol completely.
- C. Expect to see immediate results.
- D. Limit fluid intake to 1 liter per day.
Correct Answer: A
Rationale: The correct answer is A: Take folic acid supplements as prescribed. Methotrexate can lead to folic acid deficiency, so supplementing with folic acid helps prevent side effects. It is important for the nurse to educate the patient on the importance of taking folic acid to maintain overall health.
Choice B is incorrect. While it is generally recommended to limit alcohol consumption with methotrexate, avoiding it completely may not be necessary for all patients.
Choice C is incorrect. Methotrexate takes time to work, often several weeks to months, so immediate results should not be expected.
Choice D is incorrect. Limiting fluid intake to 1 liter per day is not a standard recommendation for patients taking methotrexate. Adequate hydration is important for overall health.
A client is admitted with diabetic ketoacidosis (DKA). Which assessment finding requires immediate intervention?
- A. Fruity breath odor.
- B. Blood glucose of 450 mg/dL.
- C. Deep, rapid respirations.
- D. Serum potassium of 5.2 mEq/L.
Correct Answer: C
Rationale: Step-by-step rationale:
1. Deep, rapid respirations in DKA indicate Kussmaul respirations, a compensatory mechanism for metabolic acidosis.
2. Immediate intervention is needed to prevent respiratory failure and further acidosis.
3. Administering IV fluids and insulin can help correct acidosis and stabilize breathing.
4. Fruity breath odor (A) and high blood glucose (B) are common in DKA but do not require immediate intervention.
5. Serum potassium of 5.2 mEq/L (D) is slightly elevated but not as urgent as addressing respiratory distress.