Nokea
Based on the client's blood glucose measurement, the nurse immediately reevaluates the client. Which physician orders should the nurse anticipate? Select all that apply.
- A. STAT serum blood glucose
- B. Intravenous regular insulin
- C. Vital signs every 2 hours
- D. A diet of six small, frequent meals
- E. Electronic glucometer measurements before meals and at bedtime
- F. Continuous cardiac monitoring
Correct Answer: A,B,E,F
Rationale: DKA with a glucose of 498 mg/dL requires STAT serum glucose, IV insulin, frequent glucometer checks, and cardiac monitoring.
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The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse?
- A. Serum blood glucose level of 74 mg/dL.
- B. Pulse oximeter reading of 90%.
- C. Telemetry reading showing sinus bradycardia.
- D. The client is lethargic and sleeps all the time.
Correct Answer: B
Rationale: A pulse oximetry of 90% indicates hypoxia, requiring immediate intervention in myxedema coma. Normal glucose, bradycardia, and lethargy are expected.
The nurse is caring for the client who had a thyroidectomy 2 days ago. Based on the findings of the client's serum laboratory report, which medication should the nurse plan to administer first?
- A. Potassium chloride 20 mEq oral bid
- B. Calcium gluconate 4.5 mEq IV once
- C. Dolasetron 12.5 mg IV as needed
- D. Levothyroxine 50 mcg oral daily
Correct Answer: B
Rationale: The serum calcium is critically low (6 mg/dL). Calcium gluconate addresses hypocalcemia from parathyroid gland damage during thyroidectomy.
Based on the knowledge that clients with Cushing's syndrome heal slowly, which nursing measure is most appropriate during the client's postoperative period?
- A. Monitoring infusion of I.V. antibiotics
- B. Removing tape toward the incision site
- C. Increasing the client's dietary protein intake
- D. Covering the wound with gauze
Correct Answer: C
Rationale: Increased dietary protein supports tissue repair and healing in Cushing's syndrome.
During the physical assessment of this client, which finding the nurse's blood, the observer?
- A. Shortened height
- B. Enlarged hands
- C. Gonadal atrophy
- D. Loss of teeth
Correct Answer: B
Rationale: Acromegaly, caused by excess growth hormone, leads to enlarged hands due to soft tissue and bone overgrowth.
When the client asks the nurse why regular exercise is recommended for diabetic clients, the best answer is that exercise tends to facilitate which positive outcome?
- A. Regular exercise helps to control weight.
- B. Regular exercise helps to decrease appetite.
- C. Regular exercise helps to reduce blood glucose levels.
- D. Regular exercise helps to improve circulation to the feet.
Correct Answer: C
Rationale: Exercise increases insulin sensitivity, reducing blood glucose levels in diabetes.