Nokea
The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 diabetes controlled with 70/30 insulin. Which intervention should be included in the plan of care?
- A. Assess the client's ability to read small print.
- B. Monitor the client's serum prothrombin time (PT) level.
- C. Teach the client how to perform a hemoglobin A1c test daily.
- D. Instruct the client to check the feet weekly.
Correct Answer: A
Rationale: Assessing the ability to read small print ensures the elderly client can read insulin labels and glucometer results, critical for safe management. PT is irrelevant, A1c is not daily, and foot checks are daily.
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The client is being admitted to the outpatient department prior to an endoscopic retrograde cholangiopancreatogram (ERCP) to rule out cancer of the pancreas. Which preprocedure instruction should the nurse teach?
- A. Prepare to be admitted to the hospital after the procedure for observation.
- B. If something happens during the procedure, then emergency surgery will be done.
- C. Do not eat or drink anything after midnight the night before the test.
- D. If done correctly, this procedure will correct the blockage of the stomach.
Correct Answer: C
Rationale: NPO after midnight prevents aspiration during ERCP sedation. Hospital admission, emergency surgery, and blockage correction are incorrect.
The nurse is caring for the client diagnosed with DI. Which nursing actions are most appropriate? Select all that apply.
- A. Monitoring hourly urine output and daily weights
- B. Checking urine osmolality and urine ketones
- C. Giving desmopressin acetate (DDAVP) as prescribed
- D. Checking glucose levels before meals and at bedtime
- E. Monitoring for signs or symptoms of hyperkalemia
Correct Answer: A,C
Rationale: Monitoring urine output and weights tracks fluid loss, and DDAVP replaces ADH in DI.
The male client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by the nurse is an example of the ethical principle of autonomy?
- A. Discuss the information the client told the nurse with the health-care provider and significant other.
- B. Explain it is possible the client could have a seizure if he drank fluid beyond the restrictions.
- C. Notify the health-care provider of the client's wishes and give the client fluids as desired.
- D. Allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the health-care provider.
Correct Answer: C
Rationale: Notifying the HCP and respecting the client’s fluid request honors autonomy. Sharing with others violates confidentiality, explaining risks is beneficence, and covertly giving water is unethical.
How does the nurse expect the urine that is collected for a routine urinalysis to appear?
- A. Tea-colored
- B. Pale yellow
- C. Goldless
- D. Light pink
Correct Answer: B
Rationale: In diabetes insipidus, the urine is typically dilute and pale yellow due to the large volume of water excreted.
The nurse should assess for hypocalcemia based on which client statements after a subtotal thyroidectomy?
- A. I feel tingling in my hands and feet.
- B. I have a headache.
- C. I feel sleepy.
- D. I have a sore throat.
Correct Answer: A
Rationale: Tingling in the hands and feet indicates hypocalcemia, a potential complication due to parathyroid gland damage during thyroidectomy.