Nokea
The client diagnosed with type 1 diabetes is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first?
- A. Administer 50% dextrose (IVP).
- B. Notify the health-care provider.
- C. Move the client to the ICU.
- D. Check the serum glucose level.
Correct Answer: D
Rationale: Checking glucose confirms hypoglycemia or hyperglycemia as the cause of unconsciousness, guiding treatment. Dextrose, HCP notification, or ICU transfer follow confirmation.
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Which sign/symptom should the nurse expect in the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH)?
- A. Excessive thirst.
- B. Orthopnea.
- C. Ascites.
- D. Concentrated urine output.
Correct Answer: D
Rationale: SIADH causes excessive ADH, leading to water retention, hyponatremia, and concentrated urine output due to reduced urine volume. Excessive thirst is typical of diabetes insipidus, orthopnea relates to heart failure, and ascites is linked to liver disease.
The nurse is admitting the client tentatively diagnosed with possible hyperaldosteronism. What should be the nurse's priority?
- A. Prepare for a computed tomography (CT) scan
- B. Give prn prescribed analgesic to treat headache
- C. Obtain an ECG to evaluate for dysrhythmias
- D. Assess for generalized weakness and fatigue
Correct Answer: C
Rationale: Obtaining an ECG is priority to detect dysrhythmias from hypokalemia caused by potassium wasting in hyperaldosteronism.
How does the nurse expect the urine that is collected for a routine urinalysis to appear?
- A. Tea-colored
- B. Pale yellow
- C. Goldless
- D. Light pink
Correct Answer: B
Rationale: In diabetes insipidus, the urine is typically dilute and pale yellow due to the large volume of water excreted.
The nurse is teaching a client to self-administer insulin. The instructions should include teaching the client to:
- A. inject the needle at a 90-degree angle into the muscle.
- B. vigorously massage the area after injecting the insulin.
- C. rotate injection sites.
- D. keep the open bottle of insulin in the refrigerator.
Correct Answer: C
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption. Insulin is injected subcutaneously, not into muscle, and massaging can alter absorption.
The health-care provider has ordered 40 g/24 hr of intranasal vasopressin for a client diagnosed with diabetes insipidus. Each metered spray delivers 10 g. The client takes the medication every 12 hours. How many sprays are delivered at each dosing time?
Correct Answer: 2 sprays
Rationale: Total dose: 40 g/24 hr, split every 12 hr = 20 g/dose. Each spray = 10 g, so 20 g ÷ 10 g/spray = 2 sprays per dose.