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An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?
- A. Had a cold and ear infection for the past two days
- B. Missed a dose of insulin
- C. Did not follow dietary restrictions
- D. Overexerted during exercise
Correct Answer: A
Rationale: The correct answer is A. Infections, like a cold and ear infection, increase the body's metabolic needs and insulin resistance, making diabetic ketoacidosis (DKA) more likely. While missing insulin doses or not following dietary restrictions can trigger DKA, an illness is the most common precipitating factor in pediatric Type 1 diabetes. Option B is less likely as missing insulin can lead to hyperglycemia but might not be the immediate cause of ketoacidosis. Option C can contribute to DKA over time, but the acute trigger is usually an illness. Option D, overexertion during exercise, is less likely to cause DKA compared to an infection.
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A client with a history of closed head injury has a radial artery catheter in place and complains of numbness and pain distal to the insertion site. What action should the nurse take?
- A. Monitor the site for further complications.
- B. Promptly remove the catheter from the radial artery.
- C. Elevate the client's arm above the heart.
- D. Notify the healthcare provider and prepare for surgery.
Correct Answer: B
Rationale: A weak pulse and numbness distal to a radial artery catheter may indicate occlusion or damage to the artery, and immediate removal of the catheter is necessary to prevent complications. Therefore, promptly removing the catheter from the radial artery (Choice B) is the correct action. Monitoring the site (Choice A) would delay necessary intervention, elevating the client's arm (Choice C) may not address the underlying issue, and notifying the healthcare provider for surgery (Choice D) without removing the catheter promptly could lead to further complications.
The nurse is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?
- A. Place an abduction pillow between the client's legs.
- B. Use an abduction pillow between the client's legs.
- C. Encourage the client to cross their legs while sitting.
- D. Encourage the client to sit upright for long periods.
Correct Answer: B
Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.
A client with a urinary tract infection (UTI) is prescribed ciprofloxacin. What client teaching is essential?
- A. Increase fluid intake to prevent crystalluria.
- B. Take the medication with meals to prevent GI upset.
- C. Avoid sunlight exposure while taking the medication.
- D. Report any changes in the color of urine.
Correct Answer: A
Rationale: The correct answer is to increase fluid intake to prevent crystalluria, a potential side effect of ciprofloxacin. Crystalluria is the formation of crystals in the urine, which can be reduced by maintaining adequate hydration. Choice B is incorrect because ciprofloxacin can be taken with or without food. Choice C is incorrect as avoiding sunlight exposure is more relevant for medications that cause photosensitivity, not typically a concern with ciprofloxacin. Choice D is less essential than choice A because while reporting changes in urine color is important, preventing crystalluria through adequate fluid intake is a higher priority.
A nurse is caring for a 73-year-old male client with Alzheimer's disease. Which action should the nurse take to enhance the client's nutritional intake?
- A. Encourage the client to eat large meals in one sitting.
- B. Offer the client frequent snacks of foods he enjoys.
- C. Provide the client with foods high in fiber to improve digestion.
- D. Discourage eating late at night to prevent weight gain.
Correct Answer: B
Rationale: Offering frequent snacks of foods the client enjoys is the most appropriate action to enhance the nutritional intake of a client with Alzheimer's disease. This approach helps to ensure that the client receives an adequate amount of nutrients throughout the day, especially when larger meals might be challenging for individuals with Alzheimer's. Encouraging large meals in one sitting (Choice A) may overwhelm the client and lead to decreased food intake. While foods high in fiber (Choice C) are beneficial for digestion, the primary focus should be on providing foods the client enjoys to increase intake. Discouraging eating late at night (Choice D) is not directly related to enhancing nutritional intake in this scenario.
Which of these findings should the nurse report immediately after a client has a liver biopsy?
- A. Temperature of 99.5 degrees F (37.5 degrees C)
- B. Blood pressure of 108/70
- C. Pulse oximetry reading of 96%
- D. Severe abdominal pain
Correct Answer: D
Rationale: The correct answer is D, severe abdominal pain. After a liver biopsy, severe abdominal pain is a critical finding that requires immediate reporting as it may indicate internal bleeding or damage to the liver. The other vital signs provided in choices A, B, and C are within normal limits and may not be directly related to complications post liver biopsy. Therefore, the priority is to address the severe abdominal pain promptly to prevent any further complications.