Nokea
The client with an acute exacerbation of chronic pancreatitis has a nasogastric (N/G) tube. Which interventions should the nurse implement? Select all that apply.
- A. Monitor the client's bowel sounds.
- B. Monitor the client's food intake.
- C. Assess the client's intravenous site.
- D. Provide oral and nasal care.
- E. Monitor the client's blood glucose.
Correct Answer: A,C,D,E
Rationale: Monitoring bowel sounds, IV site, oral/nasal care, and glucose manage NG tube complications and pancreatitis-related risks (e.g., hyperglycemia). Food intake is irrelevant with NPO status.
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The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, zero (0) units; 151 to 200, three (3) units; 201 to 250, six (6) units; >251, contact health-care provider. The unlicensed assistive personnel (UAP) reports to the nurse the client's glucometer reading is 189. How much insulin should the nurse administer to the client?
Correct Answer: 3 units
Rationale: Per the sliding scale, a glucose of 189 (151–200 range) requires 3 units of Humalog.
The nurse identified a concept of metabolism for a client diagnosed with diabetes. Which antecedent would be identified as placing the client at risk for diabetes?
- A. Nutrition.
- B. Sensory perception.
- C. pH regulation.
- D. Medication.
Correct Answer: A
Rationale: Poor nutrition (e.g., high sugar intake) is a key risk factor for diabetes, impacting metabolism. Sensory, pH, and medications are less directly causative.
The clinic nurse is evaluating the client with type 1 DM who intends to enroll in a tennis class. Which statement made by the client indicates that the client understands the effects of exercise on insulin demand?
- A. I will carry a high-fat, high-calorie food, such as a cookie.'
- B. I will administer 1 unit of lispro insulin prior to playing tennis.'
- C. I will eat a 15-gram carbohydrate snack before playing tennis.'
- D. I will need to rest for a while during tennis if I feel sweaty or shaky.'
Correct Answer: C
Rationale: Excessive exercise without sufficient carbohydrates can result in unexpected hypoglycemia.
Which nursing interventions are most appropriate for nursing in the health of a client with Cushing's syndrome? Select all that apply.
- A. Have the client sleep on a convoluted (egg-crate) foam mattress.
- B. Ambulate the client at frequent intervals.
- C. Advise the client to ask for assistance when getting up.
- D. Offer high-carbohydrate nourishment.
- E. Check the client frequently for suicidal ideation.
- F. Instruct the client to wear loose-fitting clothing.
Correct Answer: A,C,E,F
Rationale: These interventions address skin breakdown, fall risk, mood changes, and comfort in Cushing's syndrome.
The nurse teaches the client how the infusion pump operates and correctly points out that the infusion is typically administered in which location?
- A. In a vein within the nondominant hand
- B. In the muscular tissue of the thigh
- C. In the subcutaneous tissue of the abdomen below the belt line
- D. In an implanted I.V. catheter threaded into the neck
Correct Answer: C
Rationale: Insulin pumps deliver insulin into the subcutaneous tissue of the abdomen for consistent absorption.