Nokea
The charge nurse is making client assignments in the intensive care unit. Which client should be assigned to the most experienced nurse?
- A. The client with type 2 diabetes who has a blood glucose level of 348 mg/dL.
- B. The client diagnosed with type 1 diabetes who is experiencing hypoglycemia.
- C. The client with DKA who has multifocal premature ventricular contractions.
- D. The client with HHNS who has a plasma osmolarity of 290 mOsm/L.
Correct Answer: C
Rationale: DKA with PVCs indicates cardiac instability, requiring an experienced nurse for complex monitoring and intervention. High glucose, hypoglycemia, and normal osmolarity are less critical.
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The nurse is admitting a client to the neurological intensive care unit who is postoperative transsphenoidal hypophysectomy. Which data warrant immediate intervention?
- A. The client is alert to name but is unable to tell the nurse the location.
- B. The client has an output of 2,500 mL since surgery and an intake of 1,000 mL.
- C. The client's vital signs are T 97.6°F, P 88, R 20, and BP 130/80.
- D. The client has a 3-cm amount of dark-red drainage on the turban dressing.
Correct Answer: B
Rationale: High output (2,500 mL vs. 1,000 mL intake) suggests diabetes insipidus, requiring immediate intervention to prevent dehydration. Disorientation, normal vitals, and drainage are less urgent.
Before administering this medication, what is essential for the nurse to ask the client?
- A. Do you have trouble swallowing?
- B. Do you keep the child form of medication?
- C. Have you had digestive disorders in the past?
- D. Is there a possibility you could be pregnant?
Correct Answer: D
Rationale: Propylthiouracil is contraindicated in pregnancy due to potential teratogenic effects.
The nurse should assess for hypocalcemia based on which client statements after a subtotal thyroidectomy?
- A. I feel tingling in my hands and feet.
- B. I have a headache.
- C. I feel sleepy.
- D. I have a sore throat.
Correct Answer: A
Rationale: Tingling in the hands and feet indicates hypocalcemia, a potential complication due to parathyroid gland damage during thyroidectomy.
The diabetic client tells the nurse that breakfast is always skipped. Which response by the nurse is most appropriate?
- A. If you drink a glass of milk and eat a breakfast bar, that will be sufficient for breakfast.
- B. You should eat each meal and snack at the same time each day.
- C. If you skip breakfast, eat a high-calorie snack at midmorning.
- D. Wait to take your medication until you eat your first meal of the day.
Correct Answer: B
Rationale: Consistent meal timing is crucial for blood glucose control in diabetes.
When the client practices self-administration of the insulin, which action is correct?
- A. Piercing the skin at a 30-degree angle
- B. Using a syringe calibrated in minims
- C. Using a 29-gauge needle on the syringe
- D. Rotating abdominal sites for each injection
Correct Answer: D
Rationale: Rotating abdominal sites prevents lipodystrophy and ensures consistent insulin absorption.