Nokea
The client with type 1 DM is scheduled for major surgery in the morning. The nurse on the night shift observes that the client's daily insulin dose remains the same as previously given. Which nursing action is most appropriate?
- A. Notify the prescribing HCP about the client's surgery and ask about any insulin changes.
- B. Write an order to decrease the morning insulin dose by one-half of the prescribed dose.
- C. Do nothing; the HCP would want the client to receive the usual insulin dose prior to surgery.
- D. Have the day shift nurse check a morning glucose level and, if normal, hold the insulin dose.
Correct Answer: A
Rationale: Because the client will be NPO for surgery, the nurse should verify the insulin type and dose to be administered to prevent a hypoglycemic reaction.
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The nurse obtains a fingerstick blood glucose reading of 48 mg/dL for the client with type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse's best immediate intervention?
- A. Administer the insulin that is due now.
- B. Call the lab for a STAT serum glucose level.
- C. Have the client choose foods for a meal now.
- D. Provide juice with 15 grams of carbohydrates.
Correct Answer: D
Rationale: Hypoglycemia is treated with 15 to 20 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or 8 oz of low-fat milk.
Which laboratory data indicate to the nurse the client’s pancreatitis is improving?
- A. The amylase and lipase serum levels are decreased.
- B. The white blood cell (WBC) count is decreased.
- C. The conjugated and unconjugated bilirubin levels are decreased.
- D. The blood urea nitrogen (BUN) serum level is decreased.
Correct Answer: A
Rationale: Acute pancreatitis is characterized by elevated serum amylase and lipase levels due to pancreatic inflammation. A decrease in these levels indicates reduced pancreatic injury and improvement in the condition. While a decreased WBC count may suggest resolving infection, it is less specific. Bilirubin levels are relevant for biliary obstruction, not pancreatitis improvement, and BUN reflects renal function, not pancreatic status.
The nurse caring for a client diagnosed with cancer of the pancreas writes the nursing diagnosis of 'risk for altered skin integrity related to pruritus.' Which intervention should the nurse implement?
- A. Assess tissue turgor.
- B. Apply antifungal creams.
- C. Monitor bony prominences for breakdown.
- D. Have the client keep the fingernails short.
Correct Answer: D
Rationale: Short fingernails prevent scratching from pruritus (due to jaundice), reducing skin breakdown risk. Turgor, antifungal creams, and bony prominences are unrelated.
The nurse caring for a client diagnosed with cancer of the pancreas writes the problem of 'altered nutrition: less than body requirements.' Which collaborative intervention should the nurse include in the plan of care?
- A. Continuous feedings via (PEG) tube.
- B. Have the family bring in foods from home.
- C. Assess for food preferences.
- D. Refer to the dietitian.
Correct Answer: D
Rationale: Referring to a dietitian ensures specialized nutritional planning for pancreatic cancer, addressing malabsorption and weight loss. PEG feedings, family foods, and preferences are secondary.
Antibiotics are ordered for a client who has had a transsphenoidal hypophysectomy. He asks why he is receiving an antibiotic when he does not have an infection. The primary reason for administering antibiotics to this client is based on which information?
- A. Antibiotics will help to prevent respiratory complications following surgery.
- B. Meningitis is a complication following transsphenoidal hypophysectomy.
- C. Fluid retention can cause dangerously high cerebro spinal fluid pressure.
- D. Hormone replacement is essential after hypophysectomy.
Correct Answer: B
Rationale: The transsphenoidal approach through the mouth increases the risk of meningitis due to oral bacteria, necessitating prophylactic antibiotics.