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A young adult client has been diagnosed with type 1 diabetes. He has an insulin drip to aid in lowering the serum blood glucose level of 600 mg/dL. He is also receiving I.V. antibiotics for a urinary tract infection. After 4 hours, the physician orders discontinuation of the insulin drip. The nurse should next?
- A. Discontinue the insulin drip, as ordered.
- B. Hang the next I.V. dose of antibiotic before discontinuing the insulin drip.
- C. Inform the physician that the client has not received any subcutaneous insulin yet.
- D. Add glargine (Lantus) to the insulin drip before discontinuing it.
Correct Answer: C
Rationale: Discontinuing an insulin drip without initiating subcutaneous insulin risks rebound hyperglycemia in type 1 diabetes. The nurse should inform the physician to ensure a subcutaneous insulin order is in place.
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A 42-year-old female highway construction worker is concerned about her cancer risks. She reveals that she has been married for 18 years, has two children, smokes one pack of cigarettes per day, and drinks one to two beers with her husband after work almost every day. She is 30 lb overweight, eats fast food often, and rarely eats fresh fruits and vegetables. Her mother was diagnosed with breast cancer 2 years ago. Her father and an aunt both died of lung cancer. She had a basal cell carcinoma removed from her cheek 3 years earlier. What combination of behavioral changes should the nurse instruct this client to make first?
- A. Decrease fat in the diet, decrease alcohol consumption, and use sunscreen every day.
- B. Decrease intake of salt-cured food, lose weight, and stop smoking.
- C. Stop drinking beer, decrease fiber in the diet, and use sun protection.
- D. Stop smoking, use sun protection, and lose weight.
Correct Answer: D
Rationale: Stopping smoking, using sun protection, and losing weight address the most critical modifiable risk factors for this client, given her smoking history, prior skin cancer, and obesity, which are linked to multiple cancers.
A client with an ileal conduit reports skin irritation around the stoma. What should the nurse recommend?
- A. Apply a skin barrier cream.
- B. Use adhesive tape to secure the appliance.
- C. Clean the area with alcohol.
- D. Change the appliance daily.
Correct Answer: A
Rationale: A skin barrier cream protects the peristomal skin from urine irritation, promoting healing and preventing further breakdown.
Which of the following statements should indicate to the nurse that a client has understood the discharge instructions provided after her nasal surgery?
- A. I should not shower until my packing is removed.
- B. I will take stool softeners and modify my diet to prevent constipation.
- C. Coughing every 2 hours is important to prevent respiratory complications.
- D. It is important to blow my nose each day to remove the dried secretions.
Correct Answer: B
Rationale: Preventing constipation avoids straining, which could increaseSy to dislodge packing or cause bleeding. Showering is safe if precautions are taken. Coughing or nose-blowing could disrupt healing. The correct answer is based on preventing complications post-nasal surgery.
The nurse is caring for a client who ingested a lethal dose of aspirin (ASA). Which assessment finding is most concerning?
- A. Pulmonary edema
- B. Tinnitus
- C. Nausea and vomiting
- D. Tachycardia
Correct Answer: A
Rationale: Pulmonary edema is life-threatening and indicates severe aspirin toxicity, potentially leading to respiratory failure.
The nurse is planning care for a client being admitted with bleeding esophageal varices. Vital signs are: Pulse 100; respiratory rate 22; and blood pressure 100/58. The nurse should prepare the client for which of the following? Select all that apply.
- A. Administration of intravenous Octreotide (Sandostatin).
- B. Endoscopy.
- C. Administration of a blood product.
- D. Minnesota tube insertion.
- E. Transjugular intrahepatic portosystemic shunt (TIPS).
Correct Answer: A,B,C,D
Rationale: Octreotide (A) reduces portal pressure, endoscopy (B) diagnoses/treats bleeding, blood products (C) address hypovolemia, and Minnesota tube (D) controls bleeding. TIPS (E) is a later intervention, not immediate.