Nokea
The best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus is:
- A. Impaired Skin Integrity.
- B. Knowledge Deficit: New Diabetes Diagnosis.
- C. Alteration in Nutrition: More than Body Requirements.
- D. Fluid Volume Deficit.
Correct Answer: B
Rationale: Newly diagnosed diabetics need to learn about their disease, medications, glucose testing, possibly insulin injections, foot care, sick-day plans, and so forth.
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Prior to suctioning a tracheotomy, the nurse should:
- A. Suction the oropharynx.
- B. Administer oxygen.
- C. Change the inner cannula.
- D. Raise the head of the bed.
Correct Answer: B
Rationale: Administering oxygen pre-suctioning prevents hypoxia, as suctioning can reduce oxygen levels. Oropharyngeal suctioning, cannula changes, or bed elevation are not primary pre-suction steps.
The nurse is caring for clients on a medical/surgical unit and determines that several situations need to be addressed.
- A. Which situation should the nurse attend to first?
- B. An angry daughter is threatening to sue the hospital because her confused mother fell out of bed during the previous shift.
- C. The nursing assistant is 30 minutes overdue from a dinner break in the cafeteria for the third time this week.
- D. The physician calls the unit to ask the nurse to obtain a client’s laTest serum electrolyte results from the lab.
- E. The husband of a client reports to the nurse that his wife’s nose began bleeding after she returned from radiation therapy.
Correct Answer: D
Rationale: A nosebleed post-radiation therapy is the least stable situation, as it may indicate a serious complication like thrombocytopenia or tissue damage, requiring immediate assessment. Legal threats, staff issues, and lab result requests are less urgent than a potentially life-threatening condition.
A 4 month-old child taking digoxin (Lanoxin) has a blood pressure of 92/78; resting pulse of 78 BPM; respirations 28 and a potassium level of 4.8 mEq/L. The client is irritable and has vomited twice since the morning dose of digoxin. Which finding is most indicative of digoxin toxicity?
- A. Bradycardia
- B. Lethargy
- C. Irritability
- D. Vomiting
Correct Answer: A
Rationale: Bradycardia. The most common sign of digoxin toxicity in children is bradycardia (heart rate below 100 BPM in an infant).
The nurse is teaching a client with a new diagnosis of gout about dietary modifications. Which of the following foods should the nurse advise the client to avoid?
- A. Fresh spinach.
- B. Lean chicken breast.
- C. Canned sardines.
- D. Whole-grain pasta.
Correct Answer: C
Rationale: Canned sardines are high in purines, which increase uric acid levels and exacerbate gout. Options A, B, and D are suitable: spinach is low-purine, chicken is lean, and whole-grain pasta is not restricted.
The nurse is caring for a client with a history of burn injuries.
- A. Which intervention is most important for a client with major burn injuries?
- B. Maintain strict aseptic technique.
- C. Administer oral fluids to prevent dehydration.
- D. Apply cold compresses to burn sites.
- E. Restrict protein intake.
Correct Answer: A
Rationale: Strict aseptic technique prevents infection, a major cause of mortality in burn patients due to loss of skin barrier. IV fluids are used, cold compresses worsen tissue damage, and high-protein diets support healing.