The client has recently been diagnosed with diabetes. Which of the following indicates understanding of the management of diabetes?
- A. The client selects a balanced diet from the menu.
- B. The client can tell the nurse the normal blood glucose level.
- C. The client asks for brochures on the subject of diabetes.
- D. The client demonstrates correct insulin injection technique.
Correct Answer: D
Rationale: Demonstrating correct insulin injection technique indicates practical understanding and ability to manage diabetes effectively.
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Which type of endotracheal tube is recommended by the Centers for Disease Control (CDC) for reducing the risk of ventilator-associated pneumonia?
- A. Uncuffed
- B. CASS
- C. Fenestrated
- D. Nasotracheal
Correct Answer: B
Rationale: CASS (continuous aspiration of subglottic secretions) tubes reduce ventilator-associated pneumonia by removing secretions.
A client with recurrent episodes of gout has been advised to eat a low-purine diet. Which of the following foods should the nurse advise him to limit or avoid? Select all that apply.
- A. Liver.
- B. Sardines.
- C. Wine.
- D. Low-fat yogurt.
- E. Beef broth.
- F. Potatoes.
Correct Answer: A,B,E
Rationale: High-purine foods like liver (A), sardines (B), and beef broth (E) should be limited to reduce gout flare-ups. Wine (C), low-fat yogurt (D), and potatoes (F) are low in purines and generally safe.
The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
The nurse is responsible for performing a neonatal assessment on a fullterm infant. At 1 minute, the nurse could expect to find:
- A. An apical pulse of 100
- B. An absence of tonus
- C. Cyanosis of the feet and hands
- D. Jaundice of the skin and sclera
Correct Answer: C
Rationale: Acrocyanosis (cyanosis of hands and feet) is normal in newborns at 1 minute due to immature circulation.
A client has had diarrhea for the past 3 days. Which acid/base imbalance would the nurse expect the client to have?
- A. Respiratory alkalosis
- B. Metabolic acidosis
- C. Metabolic alkalosis
- D. Respiratory acidosis
Correct Answer: B
Rationale: Prolonged diarrhea leads to loss of bicarbonate, causing metabolic acidosis.
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