The nurse has conducted a class for pregnant clients diagnosed with diabetes mellitus about the signs/symptoms of potential complications. The nurse determines that the teaching was effective if a client makes which statement?
- A. I should not have ultrasounds done because I am diabetic.
- B. I'm glad I don't have to worry about developing hypoglycemia while I am pregnant.
- C. I need to watch my weight for any sudden gains because I could develop what they call gestational hypertension.
- D. My insulin needs should decrease during the last 2 months because I will be using some of the baby's insulin supply.
Correct Answer: C
Rationale: A diabetic pregnant client has a higher incidence of developing gestational hypertension than the nondiabetic pregnant client does. Ultrasounds are done frequently during a diabetic pregnancy to check for congenital anomalies and to determine appropriate growth patterns. Hypoglycemia is a problem during pregnancy in the client diagnosed with diabetes mellitus and needs to be assessed throughout the pregnancy. Insulin needs will increase during the last trimester because of increased hormone levels that destroy circulating insulin.
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A child is seen in the health care clinic, and testing for human immunodeficiency virus (HIV) is performed because of the child's exposure to HIV infection. Which home care instruction should the nurse provide to the parents of the child?
- A. Avoid sharing toothbrushes.
- B. Avoid all immunizations until the diagnosis is established.
- C. Wipe up any blood spills with a rag, and allow them to air-dry.
- D. Wash your hands with half-strength bleach if they come in contact with the child's blood.
Correct Answer: A
Rationale: Parents should avoid sharing toothbrushes to prevent potential HIV transmission through blood or bodily fluids. Immunizations should be kept up to date to protect the child. Blood spills should be cleaned with a paper towel, followed by soap and water, then a bleach solution, not just a rag and air-drying. Washing hands with soap and water is sufficient; bleach is too caustic for skin.
Which of the following interventions is necessary before insertion of an arterial line into the radial artery?
- A. Ensure that the client does not need surgery
- B. Assess the client's grip strength
- C. Perform an Allen test
- D. Check a serum potassium level
Correct Answer: C
Rationale: Before inserting an arterial line into the radial artery, it is crucial to perform an Allen test. The Allen test assesses the collateral circulation to the hand by compressing both the radial and ulnar arteries. By occluding the radial artery and releasing the ulnar artery, the nurse can check if the ulnar artery can adequately supply blood to the hand if the radial artery is cannulated. This step ensures that there is adequate circulation to the hand post-insertion of the arterial line.
Choice A, ensuring that the client does not need surgery, is not directly related to the insertion of an arterial line and is not a necessary step before the procedure. Choice B, assessing grip strength, is not specific to the vascular status of the hand and does not provide information about the adequacy of collateral circulation. Choice D, checking a serum potassium level, is unrelated to the assessment of radial artery patency and collateral circulation, which are the primary concerns before arterial line insertion.
A client has a prescription for ketoconazole. Which instruction should the nurse teach the client to follow while taking this medication?
- A. Avoid exposure to sunlight.
- B. Limit alcohol to 2 ounces per day.
- C. Take the medication with an antacid.
- D. Take the medication on an empty stomach.
Correct Answer: A
Rationale: The client should be taught that ketoconazole is an antifungal medication. The client should avoid exposure to sunlight because the medication increases photosensitivity. The client should avoid the concurrent use of alcohol because the medication is hepatotoxic. Antacids should be avoided for 2 hours after it is taken because gastric acid is needed to activate the medication. This medication should be taken with food or milk.
Which of the following conditions increases a client's risk of aspiration of stomach contents?
- A. A client is in restraints
- B. A client has a scaphoid abdomen
- C. A client is lying prone
- D. More than one answer is correct
Correct Answer: A
Rationale: A client in restraints is at an increased risk of aspiration of stomach contents. When a client is restrained, they may be unable to effectively move or turn their body if they begin to vomit, which can lead to aspiration. This lack of mobility can hinder their ability to protect their airway. On the other hand, a scaphoid abdomen, which is sunken or hollowed, is not a direct risk factor for aspiration. Additionally, lying prone, facing downward, does not necessarily increase the risk of aspiration, as aspiration is more likely when lying supine (facing upward). Therefore, the correct answer is that a client is in restraints.
The nurse has completed teaching with a hemodialysis client regarding the self-monitoring of the fluid status between hemodialysis treatments. The nurse determines that the client understands the information given if the client states the need to record which item(s) on a daily basis?
- A. Activity
- B. Pulse and respiratory rate
- C. Intake, output, and weight
- D. Blood urea nitrogen and creatinine levels
Correct Answer: C
Rationale: Recording daily intake, output, and weight helps monitor fluid status, ensuring no more than 0.5 kg weight gain per day between hemodialysis sessions. Activity, pulse, respiratory rate, and lab values are not daily client responsibilities.
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