Nokea
The client residing in a long-term care facility has type 2 DM and is sick with the stomach flu. The client's blood glucose is 245 mg/dL. Which action should the nurse take next?
- A. Have the client void and check the urine for ketones.
- B. Keep the client NPO until blood glucose levels decline.
- C. Immediately contact the client's health care provider.
- D. Continue to monitor blood glucose levels every 6 hours.
Correct Answer: A
Rationale: The nurse should check the client's urine for ketones whenever the blood glucose level is greater than 240 mg/dL.
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The nurse is administering morning medications. Which medications should the nurse administer question?
- A. The oral carafate to a client who has not eaten breakfast.
- B. The subcutaneous insulin to a client refusing blood glucose checks.
- C. The levothyroxine PO to a client diagnosed with hypothyroidism.
- D. The sliding scale insulin to a client whose blood glucose level is 320 mg/dL.
Correct Answer: B
Rationale: Insulin without glucose checks risks hypoglycemia, requiring clarification. Carafate timing, levothyroxine, and sliding-scale insulin are appropriate.
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.
A woman with hypothyroidism asks the nurse why the doctor told her she cannot have a sedative. The nurse's response is based on which of the following facts?
- A. Sedatives potentiate thyroid replacement medication.
- B. Clients with hypothyroidism have increased susceptibility to all sedative drugs.
- C. Sedatives will have a paradoxical effect on clients with hypothyroidism.
- D. Sedatives would cause fluid retention and hypernatremia.
Correct Answer: B
Rationale: Hypothyroidism increases sensitivity to sedatives, risking excessive sedation or respiratory depression.
Immediately after surgery, the nurse assesses the client for bleeding. Where is the best location to assess for bleeding?
- A. The skull
- B. The nose
- C. The ear canal
- D. The tongue
Correct Answer: B
Rationale: Trans-sphenoidal hypophysectomy is performed through the nasal cavity, so bleeding is most likely to be observed in the nose.
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.