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As part of the teaching plan for a client with type I diabetes mellitus, the nurse should include that carbohydrate needs might increase when:
- A. an infection is present.
- B. there is an emotional upset.
- C. a large meal is eaten.
- D. active exercise is performed.
Correct Answer: D
Rationale: Active exercise increases insulin sensitivity, thus lowering blood glucose levels. Additional carbohydrates might be needed to balance the usual insulin dose. All of the other choices increase blood glucose levels.
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The LPN is placing a Foley in a female client. Place the following steps in the appropriate order.A.Prepare the sterile field., B.Separate labia with non-dominant hand., C.Clean the urinary meatus using cleansing solutions and forceps. D. Inflate catheter balloon. E. Place the client in a supine position with flexed knees. F. Place lubricant on catheter. G. Place catheter in meatus with dominant (sterile) hand
- A. E, A, B, F, G, C, D
- B. A, E, B, F, G, D, C
- C. A, E, F, B, C, G, D
- D. E, A, F, B, C, G, D
Correct Answer: D
Rationale: The LPN should follow the correct order of catheter insertion to ensure the catheter is inserted safely. Any other variant of insertion may cause compromise of sterility and client harm.
According to the ANA Code of Ethics for Nurses, professional nurses have an ethical obligation to:
- A. clients (patients)
- B. the profession of nursing
- C. provide high-quality care
- D. all of the above
Correct Answer: D
Rationale: The ANA Code of Ethics encompasses obligations to clients, the nursing profession, and delivering high-quality care, ensuring comprehensive ethical practice.
The nurse learns at shift report that the immobile client has bilateral foot drop. Which finding during the nurse's assessment supports the presence of foot drop?
- A. The client's great toe is dorsiflexed, and the other toes are fanned out.
- B. The client's feet are unable to be maintained perpendicular to the legs.
- C. The client is unable to move the feet into a position of plantar flexion.
- D. The client is only able to dorsiflex both feet when asked to bend the feet.
Correct Answer: B
Rationale: B: Inability to hold feet perpendicular indicates foot drop. A: This describes a Babinski sign. C: Foot drop involves persistent plantar flexion, not inability to plantar flex. D: Foot drop prevents dorsiflexion.
A nurse is assessing a patient's right lower extremity. The extremity is warm to touch, red and swollen. The patient is also running a low fever. Which of the following conditions would be the most likely cause of the patient's condition?
- A. Herpes
- B. Scleroderma
- C. Dermatitis
- D. Cellulitis
Correct Answer: D
Rationale: Inflammation of cellular tissue associated with a fever most likely indicates cellulitis.
A client with an ileus is placed on intestinal tube suction. Which of the following electrolytes is lost with intestinal suction?
- A. calcium
- B. magnesium
- C. potassium
- D. sodium chloride
Correct Answer: D
Rationale: Duodenal intestinal fluid is rich in K+, Na+, and bicarbonate. Suctioning to remove excess fluids decreases the client's K+ and Na+ levels.