Nokea
The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting 'funny.' Which intervention should the nurse implement first?
- A. Instruct the UAP to obtain the blood glucose level.
- B. Have the client drink eight (8) ounces of orange juice.
- C. Go to the client's room and assess the client for hypoglycemia.
- D. Prepare to administer one (1) ampule 50% dextrose intravenously.
Correct Answer: C
Rationale: Assessing for hypoglycemia (e.g., confusion, headache) confirms the cause, as Humulin R peaks around 3 hours. UAPs cannot check glucose, and treatment follows confirmation.
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Which response by the nurse about potassium iodide (Lugol's solution) is correct?
- A. It firms the gland so it is easily removed.
- B. It decreases the postoperative recovery time.
- C. It decreases the risk of postoperative bleeding.
- D. It eliminates the need for hormone replacement.
Correct Answer: C
Rationale: Potassium iodide reduces thyroid vascularity, decreasing the risk of postoperative bleeding.
The nurse is caring for multiple clients with DM. It is most important for the nurse to initiate a referral to a diabetes educator for which client?
- A. The client who states diabetes is well controlled with diet and exercise; Hgb A1c is 11%.
- B. The client requesting diabetes information; fingerstick glucose is 132 mg/dL, Hgb A1c is 5.6%.
- C. The client who states perfect compliance with diet, exercise, and meds; Hgb A1c is 7%.
- D. The client with short-term memory loss; fingerstick glucose is 110 mg/dL, Hgb A1c is 4.5%.
Correct Answer: A
Rationale: It is most important for the nurse to initiate a referral for clients who falsely think their diabetes is well controlled. The client's Hgb A1c, which measures average blood glucose over the previous 3 months, is 11%, indicating that the diabetes is not well controlled.
The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus (DI). Which instructions should the nurse teach regarding a fluid deprivation test?
- A. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours.
- B. The client will be administered an injection of antidiuretic hormone (ADH), and urine output will be measured for four (4) to six (6) hours.
- C. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test.
- D. An IV will be started with normal saline, and the client will be asked to try to hold the urine in the bladder until a sonogram can be done.
Correct Answer: C
Rationale: The fluid deprivation test involves NPO status with hourly vitals and weights to assess urine concentration, diagnosing DI. Other options describe incorrect procedures.
The female client is to be treated with radioactive iodine (RAI) therapy for an enlarged thyroid gland. The client asks if there are any precautions that are needed during RAI therapy. Which is the nurse's best response?
- A. No precautions are necessary. The radiation in the form of an oral capsule will target and destroy thyroid tissue only.'
- B. Use contraceptives or abstain from sexual intercourse to avoid conceiving during and for 6 months after treatment.'
- C. Discontinue taking the antithyroid medication and propranolol; results are seen immediately with RAI therapy.'
- D. Some people need a thyroid hormone replacement, but it is not necessary when the thyroid gland is enlarged.'
Correct Answer: B
Rationale: Pregnancy should be postponed for at least 6 months after RAI treatment because it crosses the placenta.
When developing the client's care plan, which intervention is most appropriate to add?
- A. Encourage the client to use an electric razor.
- B. Tell the client to file rather than cut toenails.
- C. Make sure that the client receives mouth care twice per day.
- D. Advise the client to use deodorant soap when bathing.
Correct Answer: B
Rationale: Filing toenails prevents injury and infection in diabetic clients with poor healing.