Nokea
Before administering a scheduled dose of insulin to a 10-year-old child who is learning diabetic self-care, which information is most important for the PN to ask the child?
- A. How much exercise did the child have today?
- B. Did the child perform a finger stick?
- C. When did the child last urinate?
- D. Has the child eaten recently?
Correct Answer: B
Rationale: The correct answer is B: 'Did the child perform a finger stick?' Before administering insulin, it is crucial to check the child's blood glucose level to prevent hypoglycemia. Performing a finger stick blood glucose test provides essential information on the current blood sugar level. Choice A ('How much exercise did the child have today?') is not as critical as monitoring blood glucose levels directly. Choice C ('When did the child last urinate?') is not directly related to the immediate need for insulin administration. Choice D ('Has the child eaten recently?') is important but not as crucial as knowing the current blood glucose level.
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A post-operative client is recovering from a total knee replacement and is prescribed patient-controlled analgesia (PCA). What is the primary advantage of PCA for managing post-operative pain?
- A. It allows for consistent pain control without overmedication.
- B. It eliminates the need for oral pain medication.
- C. It reduces the risk of opioid addiction.
- D. It requires less monitoring by nursing staff.
Correct Answer: A
Rationale: The primary advantage of PCA for managing post-operative pain is that it allows the client to control the administration of pain medication, leading to consistent pain control without overmedication. Choice B is incorrect as PCA does not eliminate the need for oral pain medication; it supplements it. Choice C is incorrect because while PCA can help reduce opioid consumption, it does not directly reduce the risk of opioid addiction. Choice D is incorrect as PCA actually requires close monitoring by nursing staff to ensure proper use and prevent complications.
A client is post-operative day one following an open cholecystectomy. The nurse notices the client's drainage from the T-tube is dark green. What is the most appropriate action for the nurse to take?
- A. Document the finding as normal.
- B. Notify the healthcare provider immediately.
- C. Decrease the suction on the T-tube.
- D. Flush the T-tube with saline to ensure patency.
Correct Answer: A
Rationale: Dark green drainage from a T-tube after a cholecystectomy is bile, which is an expected finding. Bile is normally dark green in color. It is important for the nurse to recognize this as a normal post-operative occurrence and document the finding. There is no need to notify the healthcare provider immediately as this finding is an anticipated part of the client's recovery. Decreasing the suction on the T-tube or flushing it with saline is unnecessary and may not be indicated based on the color of the drainage. Therefore, the most appropriate action for the nurse to take is to document the dark green drainage as a normal finding.
After admission, which observation is most important for the nurse to report immediately for an adult client who weighs 150 pounds and has partial-thickness and full-thickness burns over 40% of the body from a house fire?
- A. Poor appetite and refusal to eat
- B. Systolic blood pressure at 102
- C. Painful moaning and crying
- D. Urinary output of 20 ml/hr
Correct Answer: D
Rationale: A urinary output of 20 ml/hr is a sign of inadequate kidney perfusion and could indicate hypovolemic shock, which requires immediate intervention. In this situation, with severe burns over a large portion of the body, monitoring urinary output is crucial to assess kidney function and fluid status. Poor appetite, systolic blood pressure at 102, and painful moaning and crying are important but do not indicate the immediate need for intervention like inadequate urinary output does.
A client is recovering from a right-sided mastectomy and is concerned about lymphedema. What should the nurse include in the discharge teaching to minimize this risk?
- A. Encourage wearing tight clothing on the affected arm.
- B. Advise against lifting heavy objects with the affected arm.
- C. Recommend the client sleep on the affected side.
- D. Suggest frequent massage of the affected arm.
Correct Answer: B
Rationale: The correct answer is B: Advise against lifting heavy objects with the affected arm. Lifting heavy objects with the affected arm can increase the risk of lymphedema. It is important for clients to avoid activities that strain the affected arm to minimize the risk of developing lymphedema. Choices A, C, and D are incorrect because wearing tight clothing on the affected arm, sleeping on the affected side, and frequent massage of the affected arm can potentially worsen lymphedema or impede the recovery process. Tight clothing can impede lymphatic flow, sleeping on the affected side can restrict circulation, and frequent massage can exacerbate swelling in the arm.
An adult client is undergoing weekly external radiation treatments for breast cancer and reports increasing fatigue. What action should the nurse take?
- A. Notify the healthcare provider or charge nurse immediately
- B. Offer to reschedule the treatment for the following week
- C. Plan to monitor the client's vital signs every 30 minutes
- D. Reinforce the need for extra rest periods and plenty of sleep
Correct Answer: D
Rationale: The correct action for the nurse to take when a client undergoing radiation treatment for breast cancer reports increasing fatigue is to reinforce the need for extra rest periods and plenty of sleep. Fatigue is a common side effect of radiation therapy, and adequate rest and sleep can help manage this symptom. Notifying the healthcare provider or charge nurse immediately (choice A) is not necessary for increasing fatigue, as it is expected during radiation therapy. Offering to reschedule the treatment for the following week (choice B) is not the best initial action for managing fatigue. Planning to monitor the client's vital signs every 30 minutes (choice C) is unnecessary and not directly related to managing fatigue caused by radiation therapy.