Nokea
A pediatric nurse volunteers at a health screening fair. The nurse examines a patient. Which of the following findings may be indicative of type 1 diabetes and require further investigation?
- A. stomach bloating, swollen lymph nodes, increased thirst
- B. sudden weight loss, blurry vision, muscle weakness
- C. sudden weight gain, ringing in the ears, difficulty sleeping
- D. feeling hungry all of the time, increased thirst, waking up at night to urinate
Correct Answer: D
Rationale: Type 1 diabetes presents with polyphagia, polydipsia, and polyuria (e.g., waking to urinate). Weight loss (B) is also common, but D is the most specific.
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The physician has ordered continuous bladder irrigation for a client following a prostatectomy. The nurse should:
- A. Hang the solution 2-3 feet above the client's abdomen
- B. Allow air from the solution tubing to flow into the catheter
- C. Use a clean technique when attaching the solution tubing to the catheter
- D. Clamp the solution tubing periodically to prevent bladder distention
Correct Answer: A
Rationale: Hanging the solution 2-3 feet above the abdomen ensures proper flow by gravity without excessive pressure, maintaining effective irrigation.
The charge nurse is making assignments for the day shift. One of the nurses is 5 months pregnant. Which of the following clients is the most appropriate assignment for this expectant nurse?
- A. a client with shingles
- B. a client with measles
- C. a client with pneumonia
- D. a client with Clostridium difficile
Correct Answer: C
Rationale: Pneumonia is less likely to pose a risk to a pregnant nurse compared to shingles, measles (both vaccine-preventable and highly contagious), or C. difficile (requiring strict contact precautions).
The nurse is giving an end-of-shift report when a client with a chest tube is noted in the hallway with the tube disconnected. What is the most appropriate action?
- A. Clamp the chest tube immediately
- B. Put the end of the chest tube into a cup of sterile normal saline
- C. Assist the client back to the room and place him on his left side
- D. Reconnect the chest tube to the chest tube system
Correct Answer: B
Rationale: A disconnected chest tube risks air entering the pleural space, causing pneumothorax. Placing the end in sterile saline creates a water seal, preventing air entry until reconnection.
The nurse is discharging a client with asthma who has a prescription for zafirlukast (Accolate). Which comment by the client would indicate a need for further teaching?
- A. I should take this medication with meals.'
- B. I need to report flulike symptoms to my doctor.'
- C. My doctor might order liver tests while I'm on this drug.'
- D. If I'm already having an asthma attack, this drug will not stop it.'
Correct Answer: A
Rationale: Zafirlukast should be taken on an empty stomach for better absorption. The other statements are correct: flulike symptoms and liver monitoring are relevant, and zafirlukast is not a rescue medication.
The nurse is preparing a client for discharge following the removal of a cataract. The nurse should tell the client to:
- A. Take aspirin for discomfort
- B. Avoid bending over to put on his shoes
- C. Remove the eye shield before going to sleep
- D. Continue showering as usual
Correct Answer: B
Rationale: Avoiding bending over prevents increased intraocular pressure post-cataract surgery.