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How should a healthcare provider assess a patient with potential diabetic ketoacidosis (DKA)?
- A. Monitor blood glucose and check for ketones in urine
- B. Administer insulin and provide fluids
- C. Administer potassium and check for electrolyte imbalance
- D. Administer sodium bicarbonate and monitor urine output
Correct Answer: A
Rationale: Correct answer: To assess a patient with potential diabetic ketoacidosis (DKA), healthcare providers should monitor blood glucose and check for ketones in the urine. Elevated blood glucose levels and the presence of ketones in urine are indicative of DKA. Choice B is incorrect because administering insulin and providing fluids are treatments for DKA rather than assessment measures. Choice C is incorrect as administering potassium and checking for electrolyte imbalance are interventions related to managing DKA complications, not initial assessment. Choice D is incorrect because administering sodium bicarbonate and monitoring urine output are not primary assessment actions for DKA.
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A nurse is delegating the ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. The roommate is up independently
- B. The client ambulates with his slippers on over his antiembolic stockings
- C. The client uses a front-wheeled walker when ambulating
- D. The client had pain meds 30 minutes ago
Correct Answer: C
Rationale: The correct answer is C. After knee arthroplasty, it is essential for the client to use a front-wheeled walker when ambulating to ensure stability and prevent falls. Sharing this information with the assistive personnel (AP) is crucial for the client's safety and proper rehabilitation. Choices A, B, and D are incorrect because the roommate's independence, the client's footwear over stockings, and the timing of pain medication administration are not directly related to the safe ambulation of a client post-knee arthroplasty.
A nurse is caring for a client who has a serum sodium level of 125 mEq/L. Which of the following findings should the nurse expect?
- A. Numbness of the extremities.
- B. Abdominal cramping.
- C. Bradycardia.
- D. Positive Chvostek's sign.
Correct Answer: B
Rationale: Abdominal cramping is a common manifestation of hyponatremia, as the sodium imbalance affects muscle function. Numbness of the extremities (Choice A) is more commonly associated with electrolyte imbalances such as hypocalcemia. Bradycardia (Choice C) is not typically a direct manifestation of hyponatremia. Positive Chvostek's sign (Choice D) is related to hypocalcemia, not hyponatremia.
A nurse is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse plan to assess first?
- A. A client who has sinus arrhythmia and is receiving cardiac monitoring.
- B. A client who has diabetes mellitus and a hemoglobin A1C of 6.8%.
- C. A client who has epidural analgesia and weakness in the lower extremities.
- D. A client who has a hip fracture and a new onset of tachypnea.
Correct Answer: D
Rationale: The correct answer is D. New onset of tachypnea indicates a potential respiratory complication that requires immediate attention. Assessing the client with a hip fracture and tachypnea first is crucial to address the respiratory issue and prevent further deterioration. Choices A, B, and C do not present immediate life-threatening complications that require urgent assessment compared to a new onset of tachypnea.
A healthcare provider is checking a newborn's vital signs. Which of the following methods of temperature measurement should the healthcare provider use?
- A. Rectal
- B. Axillary
- C. Oral
- D. Tympanic
Correct Answer: B
Rationale: The axillary method is the most appropriate for newborns because it is non-invasive and safe. Rectal temperature measurement can be uncomfortable and poses a risk of injury, especially in newborns. Oral temperature measurement is not recommended for newborns due to their inability to cooperate and potential inaccuracies. Tympanic temperature measurement may not be as accurate in newborns compared to older children or adults.
What is the first step in preparing a blood transfusion?
- A. Administer the blood via IV push
- B. Verify the client's blood type before starting the transfusion
- C. Warm the blood to body temperature before administration
- D. Administer diuretics to prevent fluid overload
Correct Answer: B
Rationale: The correct first step in preparing a blood transfusion is to verify the client's blood type before starting the transfusion. This step is crucial to ensure compatibility and prevent adverse reactions. Administering the blood via IV push (Choice A) is incorrect as it skips the essential step of verifying the blood type. Warming the blood to body temperature (Choice C) is important but comes after verifying the blood type. Administering diuretics (Choice D) is not part of the preparation process for a blood transfusion.