Nokea
The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. Which data should the nurse assess when administering magnesium sulfate to the client?
- A. Deep tendon reflexes.
- B. Arterial blood gases.
- C. Skin turgor.
- D. Capillary refill time.
Correct Answer: A
Rationale: Magnesium sulfate administration risks toxicity, especially in hypomagnesemia. Depressed deep tendon reflexes are an early sign of magnesium toxicity, requiring close monitoring. Arterial blood gases, skin turgor, and capillary refill are unrelated to magnesium therapy.
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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.
The nurse is caring for the client with type 2 DM. Which instructions should the nurse provide to the client regarding diabetes management during stress or illness? Select all that apply.
- A. Notify the health care provider if unable to keep fluids or foods down.
- B. Test fingerstick glucose levels and urine ketones daily and keep a record.
- C. Continue to take oral hypoglycemic medications and/or insulin as prescribed.
- D. Supplement food intake with carbohydrate-containing fluids, such as juices or soups.
- E. When on an oral agent, administer insulin in addition to the oral agent during the illness.
- F. A minor illness, such as the flu, usually does not affect the blood glucose and insulin needs.
Correct Answer: A,C
Rationale: Notifying the HCP prevents dehydration, and continuing medications manages hyperglycemia during illness.
The nurse is developing a plan of care for the client diagnosed with acquired immunodeficiency syndrome (AIDS) who has developed an infection in the adrenal gland. Which client problem is highest priority?
- A. Altered body image.
- B. Activity intolerance.
- C. Impaired coping.
- D. Fluid volume deficit.
Correct Answer: D
Rationale: Adrenal infection may impair aldosterone production, causing fluid volume deficit (hypovolemia), a priority. Body image, activity, and coping are psychosocial and secondary.
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.
The nurse and an unlicensed assistive personnel (UAP) are caring for clients on an oncology floor. Which intervention should the nurse delegate to the UAP?
- A. Assist the client with abdominal pain to turn to the side and flex the knees.
- B. Monitor the Jackson Pratt drainage tube to ensure it is draining properly.
- C. Check to see if the client is sleeping after pain medication is administered.
- D. Empty the bedside commode of the client who has been having melena.
Correct Answer: A
Rationale: Assisting with positioning is within the UAP’s scope and promotes comfort. Monitoring drains, assessing sleep, and handling melena require RN skills.