Nokea
The nurse administers 15 units of glargine insulin at 2100 hours to the client when the client's fingerstick blood glucose reading is 110 mg/dL. At 2300, an NA reports that an evening snack was not given because the client was sleeping. Which instruction by the nurse is most appropriate?
- A. You will need to wake the client to check the blood glucose and then give a snack. All diabetics get a snack at bedtime.'
- B. It is not necessary for this client to have a snack; glargine insulin is absorbed over 24 hours and doesn't have a peak.'
- C. The next time the client wakes up, check a blood glucose level and then give a 15-gram carbohydrate snack.'
- D. I will notify the HCP; a snack at this time will affect the next blood glucose level and dose of glargine insulin.'
Correct Answer: B
Rationale: The onset of glargine is 1 hour; it has no peak action, and it lasts for 24 hours. Because it has no peak action, a bedtime snack is unnecessary.
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Preoperatively, which information is most important to teach the client before the subtotal thyroidectomy?
- A. Techniques for changing positions
- B. Reasons for performing leg exercises
- C. The necessity for daily dressing changes
- D. Postoperative use of the incentive spirometer
Correct Answer: D
Rationale: Using an incentive spirometer postoperatively helps prevent respiratory complications after thyroidectomy.
As the nurse provides care for the client newly diagnosed with a large goiter, which interventions should be implemented? Select all that apply.
- A. Observe the client's respiratory status
- B. Elevate the head of the client's bed
- C. Provide a diet high in food used.
- D. Obtain an order for a soft diet
- E. Assess for high fever
- F. Administer prescribed antibiotics
Correct Answer: A,B,D
Rationale: A large goiter can compress the trachea, necessitating respiratory monitoring, head elevation, and a soft diet to ease swallowing.
Which sign is most suggestive that a client with type 2 diabetes is developing hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. The client's serum glucose level is 650 mg/dL.
- B. The client's urinary output is 3,000 mL/24 hours.
- C. The client's skin is cool and moist.
- D. The client's urine contains acetone.
Correct Answer: A
Rationale: A serum glucose level of 650 mg/dL is characteristic of HHNS, indicating severe hyperglycemia.
The nurse writes a problem of 'altered body image' for a 34-year-old client diagnosed with Cushing's disease. Which intervention should be implemented?
- A. Monitor blood glucose levels prior to meals and at bedtime.
- B. Perform a head-to-toe assessment on the client every shift.
- C. Use therapeutic communication to allow the client to discuss feelings.
- D. Assess bowel sounds and temperature every four (4) hours.
Correct Answer: C
Rationale: Therapeutic communication addresses body image concerns (e.g., moon face, weight gain) in Cushing’s, promoting coping. Glucose, assessments, and bowel sounds are unrelated.
A client has a transsphenoidal hypophysectomy to remove a pituitary tumor. When the client returns to the nursing unit following surgery, the head of the bed is elevated 30 degrees. What is the primary purpose for placing the client in this position?
- A. To promote respiratory effort
- B. To reduce pressure on the sella turcica
- C. To prevent acidosis
- D. To promote oxygenation
Correct Answer: B
Rationale: Elevating the head 30 degrees reduces pressure on the sella turcica, minimizing the risk of cerebrospinal fluid leakage post-hypophysectomy.