Nokea
The home health care nurse is caring for a 30-year-old woman with type I diabetes mellitus.
- A. What should the nurse expect the physician to order for a client with type I diabetes and morning SMBG readings of 205 mg/dL and 233 mg/dL?
- B. Reduce the client’s diet to 1,500 calorie ADA.
- C. Order 3 additional units of NPH insulin at 10 PM.
- D. Order an additional 10 units of regular insulin at 8 PM.
- E. Eliminate the client’s bedtime snack.
Correct Answer: B
Rationale: Elevated morning blood glucose levels suggest the dawn phenomenon, where blood sugar rises in the early morning due to hormonal changes. Adding 3 units of NPH insulin at 10 PM addresses this by providing longer-acting insulin coverage. Reducing the diet, adding regular insulin, or eliminating the snack does not target the dawn phenomenon effectively.
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An unaccompanied client who is six months pregnant is admitted to the nursing unit with vaginal bleeding.
Which of the following comments, if made by the client, would indicate a need for the nurse to assess the adequacy of the client's emotional support?
- A. My husband will be so angry with me if I lose this baby.
- B. I'm afraid I am going to lose my baby.
- C. I can't stay here. I don't have any insurance.
- D. I feel so guilty. I didn't want to get pregnant.
Correct Answer: A
Rationale: Strategy: Think about what the words mean. (1) correct-client's concern about her husband's feelings indicates that he may not be able to support her emotionally at this time (2) reflects a reality-based concern (3) indicates an economic concern (4) indicates client needs to talk about her current feelings; does not give any indication of level of emotional support
A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
- A. Notify the RN.
- B. Assess the client for a distended bladder.
- C. Apply oxygen at 3 L/min.
- D. Increase the IV fluids.
Correct Answer: B
Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder or bowel in clients with spinal cord injuries above T6. Assessing and addressing the trigger, such as a distended bladder, is the most appropriate action. Notifying the RN may be necessary but is not the immediate action, so answer A is incorrect. Oxygen and increased IV fluids do not address the cause, so answers C and D are incorrect.
The nurse is preparing to discharge a client after an abdominal cholecystectomy for treatment of cholelithiasis. The client will go home with a T-tube in place. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. It will be great to finally get home, take a shower, and wash my hair.
- B. If the amount of drainage increases over the next several days, I should call my physician.
- C. I can resume swimming laps three times a week at my health club.
- D. I will check the skin around the tube once a day to see how it is doing.
Correct Answer: C
Rationale: Swimming submerges the T-tube, risking infection, indicating a need for further teaching. Options A, B, and D are correct: showering is allowed, increased drainage requires reporting, and daily skin checks prevent complications.
A client hospitalized with a fractured mandible is to be discharged. Which piece of equipment should be kept on the client with a fractured mandible?
- A. Wire cutters
- B. Oral airway
- C. Pliers
- D. Tracheostomy set
Correct Answer: A
Rationale: Wire cutters are essential for a fractured mandible with wiring, in case of emergency airway obstruction. Oral airway , pliers , and tracheostomy set are not standard.
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 90 mg/dL.
- B. Heart rate of 80 bpm.
- C. Sweating and confusion.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: C
Rationale: Sweating and confusion indicate hypoglycemia, a serious complication of insulin lispro, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 90 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.