Nokea
The nurse evaluates the client who is being treated for DKA. Which finding indicates that the client is responding to the treatment plan?
- A. Eyes sunken and skin flushed
- B. Skin moist with rapid elastic recoil
- C. Serum potassium level is 3.3 mEq/L
- D. ABG results are pH 7.25, PaCO2 30, HCO3 17
Correct Answer: B
Rationale: Moist skin and good skin turgor indicate that dehydration secondary to hyperglycemia is resolving.
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Which interrelated concepts could be identified as actual or potential for a 56-year-old male client diagnosed with diabetes mellitus type 2? Select all that apply.
- A. Nutrition.
- B. Metabolism.
- C. Infection.
- D. Male reproduction.
- E. Skin integrity.
Correct Answer: A,B,C,E
Rationale: Nutrition, metabolism, infection, and skin integrity are impacted by type 2 diabetes due to dietary needs, glucose control, infection risk, and neuropathy. Male reproduction is less directly affected.
The client ate 45 g of carbohydrate (carb) with the dinner meal. The client is to receive 2 units of aspart insulin subcutaneously for each carb choice (CHO) eaten (1 carb choice = 15 g). Which syringe shows the correct amount of insulin that the nurse should administer?
- A. Illustration 1: 16 units
- B. Illustration 2: 29 units
- C. Illustration 3: 1 unit
- D. Illustration 4: 6 units
Correct Answer: D
Rationale: The client should receive 6 units of insulin. Eating 45 g of carbohydrates equals 3 CHOs. If the client is to receive 2 units of insulin for each CHO, the total amount of aspart insulin is 3 CHO times 2 units per CHO = 6 units.
The nurse is caring for the client admitted in Addisonian crisis. Which medication, if prescribed, should the nurse plan to administer?
- A. Regular insulin
- B. Ketoconazole
- C. Sodium nitroprusside
- D. Hydrocortisone
Correct Answer: D
Rationale: Hydrocortisone is a corticosteroid used to replace deficient glucocorticoids in Addisonian crisis.
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.