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For proper foot care, the nurse should provide a patient with non-insulin dependent mellitus with instructions to:
For proper foot care, the nurse should provide a patient with non-insulin dependent mellitus with instructions to:
- A. Remove all corns and stop smoking.
- B. Always wear shoes and use natural fiber socks.
- C. Wear nylon socks and wash feet in warm water.
- D. Wear shoes that are slightly larger and avoid corn removers.
Correct Answer: B
Rationale: Wearing shoes and natural fiber socks protects diabetic feet and promotes circulation.
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The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
- A. I should have a bottle of Ipecac for each of my children.'
- B. I should induce vomiting if my child swallows lighter fluid.'
- C. Giving my child water or milk may help dilute the poison.'
- D. Proper storage is the key to poison prevention in the home.'
Correct Answer: B
Rationale: Inducing vomiting after ingesting hydrocarbons like lighter fluid is contraindicated due to the risk of aspiration, which can cause severe lung damage. Choice A is correct (Ipecac dosing is appropriate), choice C is accurate (dilution can help), and choice D is true (locked storage prevents poisoning). Further teaching is needed for choice B.
The nurse is caring for a client with a history of bipolar disorder who is prescribed lithium. Which of the following laboratory values should the nurse monitor?
- A. Serum sodium.
- B. Serum glucose.
- C. Serum calcium.
- D. Serum hemoglobin.
Correct Answer: A
Rationale: Lithium can cause hyponatremia, and monitoring serum sodium ensures safe levels (therapeutic lithium range: 0.6–1.2 mEq/L). Glucose (B), calcium (C), and hemoglobin (D) are not directly affected by lithium therapy.
A patient with a diagnosis of bipolar disorder has been drinking copious amounts of water and voiding frequently. The patient is experiencing muscle cramps, twitching, and is reporting dizziness.
The nurse checks lab work for
- A. complete blood count results, particularly the platelets.
- B. electrolytes, particularly the serum sodium.
- C. urine analysis, particularly for the presence of white blood cells.
- D. EEG.
Correct Answer: B
Rationale: Symptoms suggest hyponatremia from excessive water intake, requiring electrolyte assessment.
The client is being treated with intravenous Vancomycin for MRSA when the nurse notes redness of the client's neck and chest. Place in ordered sequence the actions to be taken by the nurse:
- A. Call the doctor.
- B. Stop the IV infusion of Vancomycin.
- C. Administer Benadryl as ordered.
- D. Take the vital signs.
Correct Answer: B,D,C,A
Rationale: Redness suggests an allergic reaction or 'red man syndrome' from rapid vancomycin infusion. The nurse should: stop the infusion to prevent further reaction, take vital signs to assess severity, administer Benadryl if ordered, and call the doctor for further orders.
The nurse is caring for an adult who has ulcerative colitis. When planning care, the nurse knows that which nursing diagnosis is of highest priority?
- A. Deficient fluid volume
- B. Disturbed body image
- C. Risk for impaired skin integrity
- D. Risk for ineffective health maintenance
Correct Answer: A
Rationale: Ulcerative colitis causes diarrhea, leading to fluid loss and dehydration, making deficient fluid volume the highest priority to prevent systemic complications like hypovolemia.