Nokea
The client is immediate postprocedure endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse implement?
- A. Assess for rectal bleeding.
- B. Increase fluid intake.
- C. Assess gag reflex.
- D. Keep in supine position.
Correct Answer: C
Rationale: ERCP involves throat anesthesia; assessing the gag reflex ensures safe swallowing post-procedure. Rectal bleeding, fluids, and supine positioning are irrelevant.
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The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result?
- A. This result is below normal levels.
- B. This result is within acceptable levels.
- C. This result is above recommended levels.
- D. This result is dangerously high.
Correct Answer: C
Rationale: An A1c of 8.1% is above the recommended target (<7% for most diabetics), indicating poor glycemic control. It is not normal, acceptable, or dangerously high (e.g., >10%).
To prepare for potential postoperative complications related to the thyroidectomy, which item is necessary to keep at the client's bedside?
- A. Dressing change kit
- B. Tracheostomy tray
- C. Ampule of epinephrine
- D. Mechanical ventilator
Correct Answer: B
Rationale: A tracheostomy tray is essential in case of airway obstruction due to swelling or hematoma post-thyroidectomy.
The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem 'high risk for hyperglycemia related to noncompliance with the medication regimen.' Which statement is an appropriate short-term goal for the client?
- A. The client will have a blood glucose level between 90 and 140 mg/dL.
- B. The client will demonstrate appropriate insulin injection technique.
- C. The nurse will monitor the client's blood glucose levels four (4) times a day.
- D. The client will maintain normal kidney function with 30-mL/hr urine output.
Correct Answer: B
Rationale: Demonstrating correct insulin injection technique addresses noncompliance, a short-term, client-centered goal. Glucose levels and kidney function are outcomes, and nurse monitoring is not client-focused.
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.
An adolescent with newly diagnosed Type I diabetes mellitus asks the nurse if he can continue to play football. What is the best answer for the nurse to give?
- A. Now that you have diabetes, you should not play football because you may get a cut that will not heal.'
- B. If you work with your physician to regulate the insulin dosage and your diet, you should be able to play football.'
- C. It would be better for you to work as equipment manager so you will not be under as much stress.'
- D. You can probably continue to play football if you can regulate it so that you have the same amount of exercise each day.'
Correct Answer: B
Rationale: With proper insulin and diet management, the adolescent can safely play football, supporting physical activity and normalcy.