Nokea
If the screening includes a measurement of postprandial blood glucose, the nurse is correct in explaining that blood will be drawn at which time?
- A. Approximately 2 hours before breakfast
- B. Approximately 2 hours after a meal
- C. Approximately 2 hours before bedtime
- D. Approximately 2 hours after fasting
Correct Answer: B
Rationale: Postprandial blood glucose is measured 2 hours after a meal to assess glucose metabolism.
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Which question should the nurse ask when assessing the client for an endocrine dysfunction?
- A. Have you noticed any pain in your legs when walking?
- B. Have you had any unexplained weight loss?
- C. Have you noticed any change in your bowel movements?
- D. Have you experienced any joint pain or discomfort?
Correct Answer: B
Rationale: Unexplained weight loss is a hallmark symptom of endocrine disorders like hyperthyroidism or diabetes mellitus, making it a key assessment question. Leg pain relates to vascular issues, bowel changes are less specific, and joint pain is more musculoskeletal.
Which arterial blood gas results should the nurse expect in the client diagnosed with diabetic ketoacidosis?
- A. pH 7.34, PaO2 99, PaCO2 48, HCO3 24.
- B. pH 7.38, PaO2 95, PaCO2 40, HCO3 22.
- C. pH 7.46, PaO2 85, PaCO2 30, HCO3 26.
- D. pH 7.30, PaO2 90, PaCO2 30, HCO3 18.
Correct Answer: D
Rationale: DKA causes metabolic acidosis (low pH 7.30, low HCO3 18) with compensatory respiratory alkalosis (low PaCO2 30). Other options show normal or alkalotic states.
Which medication order should the nurse question in the client diagnosed with untreated hypothyroidism?
- A. Thyroid hormones.
- B. Oxygen.
- C. Sedatives.
- D. Laxatives.
Correct Answer: C
Rationale: Sedatives risk respiratory depression in untreated hypothyroidism due to slowed metabolism. Thyroid hormones, oxygen, and laxatives are appropriate.
The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing diagnosis of 'risk for altered skin integrity related to pruritus.' Which intervention should the nurse implement?
- A. Assess tissue turgor.
- B. Apply antifungal creams.
- C. Monitor bony prominences for breakdown.
- D. Have the client keep the fingernails short.
Correct Answer: D
Rationale: Short fingernails prevent scratching from pruritus (due to jaundice), reducing skin breakdown risk. Turgor, antifungal creams, and bony prominences are unrelated.
Antibiotics are ordered for a client who has had a transsphenoidal hypophysectomy. He asks why he is receiving an antibiotic when he does not have an infection. The primary reason for administering antibiotics to this client is based on which information?
- A. Antibiotics will help to prevent respiratory complications following surgery.
- B. Meningitis is a complication following transsphenoidal hypophysectomy.
- C. Fluid retention can cause dangerously high cerebro spinal fluid pressure.
- D. Hormone replacement is essential after hypophysectomy.
Correct Answer: B
Rationale: The transsphenoidal approach through the mouth increases the risk of meningitis due to oral bacteria, necessitating prophylactic antibiotics.