Nokea
The client is scheduled for a glucose tolerance test. Place in ordered response the correct sequence for performance of this test.
- A. Instruct the client to drink a 75 gm glucose solution.
- B. Tell the client to eat a high carbohydrate diet for three days prior to the exam.
- C. Instruct the client to remain NPO after midnight.
- D. Obtain a fasting blood glucose level.
- E. Obtain a two-hour post-prandial glucose level.
Correct Answer: B,C,D,A,E
Rationale: When placing in chronological order, the nurse should: tell the client to increase the amount of carbohydrates for three days prior to the exam; instruct the client to remain NPO after midnight the day of the exam; obtain a fasting blood glucose level; instruct the client to drink a 75 gm glucose solution; and obtain a two-hour post-prandial glucose level. The candidate is asked to place answers in a logical sequence. Think about the natural order of the question.
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The nurse is talking with the parents of an adolescent client who was brought to the emergency department after making superficial cuts on the arms with a razor blade. There are several cuts in various stages of healing on the client’s forearms. Which of the following statements would be appropriate for the nurse to make? Select all that apply.
- A. This must be difficult for you
- B. Everything is going to be alright
- C. We have cleaned and bandaged the cuts
- D. Why did you wait until now to bring your child here?
- E. Tell me about when you started noticing this behavior
Correct Answer: A,C,E
Rationale: Acknowledging difficulty, confirming care, and exploring behavior onset are supportive and therapeutic. Assuring everything will be alright is dismissive, and questioning delay is judgmental.
A woman in a residence facility is having difficulty sleeping at night. Which action by the nurse is most appropriate initially?
- A. Ask the physician for a sleeping medication
- B. Offer the woman a back rub and warm milk
- C. Suggest to the woman that she take a walk around the unit
- D. Offer the woman a cup of hot tea
Correct Answer: B
Rationale: A back rub and warm milk promote relaxation non-pharmacologically, addressing insomnia safely. Medication, walking, or tea (caffeine) are less appropriate.
All of the following clients need attention. Which one should the nurse go to first?
- A. The nursing assistant reports that a client who had a T3 spinal cord transection several months ago has a severe headache and blurred vision.
- B. The nursing assistant needs help turning a client who had a CVA.
- C. The physician is about to examine a client who has multiple sclerosis and requests that the nurse be present.
- D. A client who has amyotrophic lateral sclerosis needs help with ambulating.
Correct Answer: A
Rationale: Severe headache and blurred vision in spinal cord injury suggest autonomic dysreflexia, a life-threatening emergency, prioritizing immediate attention over turning, examination, or ambulation.
The nurse is administering a tap water enema when the client begins to complain of abdominal cramping. The nurse should:
- A. Stop the administration of the enema.
- B. Lower the height of the enema container.
- C. Clamp the enema tubing and withdraw it slowly.
- D. Advance the tubing 1-2 inches.
Correct Answer: B
Rationale: Lowering the enema container slows the flow, reducing cramping. Stopping or withdrawing the tubing is premature, and advancing may worsen discomfort.
A 6-month old is brought to the ER by her mother. During the assessment, the nurse finds multiple bruises in different stages of healing and decreased range of motion of the right leg. X-ray confirms a fracture of the right femur. Which statement made by the mother would contribute to a diagnosis of child abuse?
- A. She got her leg caught in the crib and twisted it.
- B. She hurt her leg while she was crawling.
- C. I can't remember her falling or getting hurt.
- D. She fell out of her car seat before I could get the belt fastened.
Correct Answer: C
Rationale: The mother's inability to recall any injury event, combined with multiple bruises and a femur fracture, raises suspicion of child abuse due to inconsistent history.