Nokea
The most important information for the nurse to have when planning care for the client with diabetes is the client's
- A. Family medical history
- B. Blood glucose history
- C. 24-hour dietary history
- D. Medical history
Correct Answer: B
Rationale: Answer B is correct. The most objective answer is the blood glucose history. Answers A, C, and D are more subjective. This information is reported data.
You may also like to solve these questions
The nurse is performing tracheostomy care for a client who has a tracheostomy tube with a disposable inner cannula. Which of the following actions should the nurse take?
- A. Cleanse the stoma using an alcohol-based cleaning solution.
- B. Discontinue humidification once tracheostomy care is complete.
- C. Suction the tracheostomy tube prior to removing the inner cannula.
- D. Remove the outer cannula of the tracheostomy and rinse with sterile water.
Correct Answer: C
Rationale: Suctioning before removing the inner cannula (C) clears secretions and ensures airway patency. Alcohol-based solutions (A) are irritating, humidification (B) is needed, and removing the outer cannula (D) is unsafe.
The clinic nurse is reinforcing teaching to a client about the advance directive form that needs to be completed. Which statement indicates that the client understands the information?
- A. I will give a copy of this to my daughter, who is listed as my health care proxy.'
- B. I will need to get this approved by my doctor before it goes into effect.'
- C. I will put this on my refrigerator so no one will give me cardiopulmonary resuscitation.'
- D. You and my daughter can witness this for me.'
Correct Answer: A
Rationale: Giving a copy to the health care proxy (A) ensures the advance directive is communicated. Doctor approval (B), refrigerator posting (C), and nurse witnessing (D) are incorrect or unnecessary.
The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse
- A. verifies that gel is present on each electrode and is not dried out
- B. cleanses and dries the skin before placing the electrodes on the client
- C. clips excessive hair off the client before applying the electrodes
- D. places one electrode each on the client's upper and lower extremities
Correct Answer: D
Rationale: Placing electrodes on extremities (D) is incorrect for cardiac monitoring, which requires chest placement. Verifying gel (A), cleansing skin (B), and clipping hair (C) are appropriate.
The nurse is preparing to administer a sodium polystyrene sulfonate retention enema. Which explanation by the nurse best describes the purpose of this type of enema?
- A. A contrast medium is administered rectally to visualize the colon via x-ray'
- B. Bedridden clients receive this enema to stimulate defecation and relieve constipation.'
- C. This enema assists the large intestines in removing excess potassium from the body.'
- D. This enema is administered before bowel surgery to decrease bacteria in the colon.'
Correct Answer: C
Rationale: Sodium polystyrene sulfonate (C) removes excess potassium via the intestines, used in hyperkalemia. Other options describe unrelated procedures.
A client who is being evaluated for suspected ectopic pregnancy reports sudden-onset, severe, right lower abdominal pain and dizziness. Which of the following additional assessment findings will the nurse anticipate if the client is experiencing a ruptured ectopic pregnancy? Select all that apply.
- A. Blood pressure 82/64 mm Hg
- B. Crackles on auscultation
- C. Distended jugular veins
- D. Pulse 120/min
- E. Shoulder pain
Correct Answer: A, D, E
Rationale: Low blood pressure (A), tachycardia (D), and shoulder pain (E) indicate hemorrhage from a ruptured ectopic pregnancy. Crackles (B) and jugular vein distension (C) are unrelated.