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An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)
- A. Check his fingerstick glucose level
- B. Assess his skin temperature and moisture
- C. Measure his pulse and blood pressure
- D. Document anxiety on the surgical checklist
Correct Answer: C
Rationale: These actions help assess for hypoglycemia, a common issue in diabetic patients, and ensure appropriate intervention.
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After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myelinolysis. Which intervention should the nurse implement first?
- A. Reorient client to his room
- B. Place a patch on one eye
- C. Evaluate client's ability to swallow
- D. Perform range of motion exercises
Correct Answer: A
Rationale: Reorienting the client helps in managing confusion and disorientation, which are common in pontine myelinolysis.
Pulsus paradoxus is associated with
- A. pericarditis
- B. endocarditis
- C. rheumatic fever
- D. myocarditis
Correct Answer: A
Rationale: Pulsus paradoxus is commonly associated with pericardial diseases such as constrictive pericarditis.
A nurse cares for a client who is prescribed magnetic resonance imaging (MRI) of the heart. The client’s health history includes a previous myocardial infarction and pacemaker implantation. Which action should the nurse take?
- A. Schedule an electrocardiogram just before the MRI.
- B. Notify the healthcare provider before scheduling the MRI.
- C. Call the physician and request a laboratory draw for cardiac enzymes.
- D. Instruct the client to increase fluid intake the day before the MRI.
Correct Answer: B
Rationale: Clients with pacemakers are generally not candidates for MRI due to the risk of device malfunction or tissue damage. The healthcare provider must be notified to determine the best course of action.
Ejection systolic murmur in outflow in a neonate is least likely to be due to
- A. Subaortic membrane
- B. Unicuspid aortic valve
- C. Bicuspid aortic valve
- D. Pulmonary stenosis
Correct Answer: A
Rationale: Subaortic membrane is least likely to cause an ejection systolic murmur in a neonate.
A nurse assesses a client who had a myocardial infarction and is hypotensive. Which additional assessment finding should the nurse expect?
- A. Heart rate of 120 beats/min
- B. Cool, clammy skin
- C. Oxygen saturation of 90%
- D. Respiratory rate of 8 breaths/min
Correct Answer: A
Rationale: A heart rate of 120 beats/min (tachycardia) is a common compensatory response to hypotension following a myocardial infarction, as the body attempts to maintain cardiac output.