In which position will you place your patient when they are demonstrating the signs and symptoms of hypovolemic shock?
- A. The Trendelenburg position
- B. The supine position
- C. The left lateral position
- D. The right lateral position
Correct Answer: A
Rationale: The correct answer is A, the Trendelenburg position. This position involves placing the patient with their legs elevated higher than their head. It is used to increase blood flow to the upper body, including the brain and heart, in cases of hypovolemic shock. This helps improve perfusion to vital organs. Choices B, C, and D are incorrect as they do not facilitate the desired redistribution of blood flow needed in hypovolemic shock. The supine position is lying flat on the back, the left lateral position is lying on the left side, and the right lateral position is lying on the right side.
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A nurse is preparing to discharge a client who has end-stage heart failure. The client's partner tells the nurse she can no longer handle caring for the client. Which of the following actions should the nurse take?
- A. Request another family member to assist the client's partner with care
- B. Recommend the partner to place the client in a long-term care facility
- C. Contact the case manager to discuss discharge options
- D. Ask the provider to delay the client's discharge home for a few more days
Correct Answer: C
Rationale: The nurse should contact the case manager to discuss discharge options and support the client's partner. This action is appropriate as it involves seeking professional guidance and support for the client's partner who is struggling to care for the client. Option A is not the best choice as it solely focuses on involving another family member without addressing the partner's concerns directly. Option B is premature as recommending long-term care should be a well-considered decision involving multiple healthcare professionals. Option D delays the inevitable without providing a solution to the partner's current challenges.
A nurse caring for a group of clients reviews the electrolyte laboratory results and notes a sodium level of 130 mEq/L on one client's laboratory report. The nurse understands that which client is at highest risk for the development of a sodium value at this level?
- A. The client with renal failure
- B. The client who is taking diuretics
- C. The client with hyperaldosteronism
- D. The client who is taking corticosteroids
Correct Answer: B
Rationale: The correct answer is B. Clients taking diuretics are at risk for hyponatremia due to excessive sodium loss. In this scenario, a sodium level of 130 mEq/L indicates hyponatremia, which is commonly associated with diuretic use. Options A, C, and D are not the highest risk factors for developing low sodium levels in this context. Renal failure, hyperaldosteronism, and corticosteroid use are not directly linked to sodium loss as seen with diuretics.
A client with type 1 DM has a finger stick glucose level of 258mg/dl at bedtime. An order for sliding scale insulin exists. The nurse should:
- A. Call the physician
- B. Encourage the intake of fluids
- C. Administer the insulin as ordered
- D. Give the client ½ cup of orange juice
Correct Answer: C
Rationale: In this scenario, the client with type 1 DM has a high glucose level at bedtime. The appropriate action for the nurse is to administer the sliding scale insulin as ordered. This insulin regimen is specifically designed to manage high blood glucose levels. Calling the physician is not necessary as the protocol for sliding scale insulin is already in place. Encouraging fluid intake or providing orange juice is not the correct intervention for addressing high blood glucose levels in this case.
Rotating injection sites when administering insulin prevents which of the following complications?
- A. Insulin edema
- B. Insulin lipodystrophy
- C. Insulin resistance
- D. Systemic allergic reactions
Correct Answer: B
Rationale: Rotating injection sites when administering insulin helps prevent insulin lipodystrophy, which is the abnormal distribution of fat at injection sites. Insulin edema (choice A) is not prevented by rotating injection sites; it is characterized by swelling at the site of insulin injection due to increased capillary permeability. Insulin resistance (choice C) is a condition where the body's cells become less responsive to insulin, and rotating injection sites does not directly prevent this. Systemic allergic reactions (choice D) are not specifically prevented by rotating injection sites; they are related to an allergic response to insulin.
Your patient has been diagnosed with giant cell arthritis. What medication will this patient most likely be given?
- A. High doses of aspirin
- B. High doses of prednisone
- C. Methotrexate
- D. Albuterol
Correct Answer: B
Rationale: High doses of prednisone are commonly prescribed for giant cell arthritis to reduce inflammation. Aspirin is not typically used for this condition. Methotrexate is more commonly used for conditions like rheumatoid arthritis, not giant cell arthritis. Albuterol is a bronchodilator used for respiratory conditions, not for giant cell arthritis.
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