Nokea
The nurse has just received report from the previous shift. Which of the following clients should the nurse see FIRST?
- A. A client with chronic renal failure complaining of swollen fingers and ankle edema.
- B. A client one-day postoperative after abdominal surgery who has dried blood on the abdominal dressing.
- C. A client with type I diabetes mellitus who states, 'I have this quivering feeling in my abdomen.'
- D. A client on high doses of antibiotics for a resistant infection who complains of diarrhea.
Correct Answer: C
Rationale: indicates hypoglycemia; symptoms include tachycardia, cold and clammy skin, weakness and pallor; check blood sugar, offer milk
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The nurse is caring for a client who is postoperative day 2 after a bowel resection. Which of the following findings would be of GREATest concern to the nurse?
- A. Absence of bowel sounds.
- B. Temperature of 99.8°F (37.7°C).
- C. Pain at the incision site.
- D. Urine output of 30 mL/hour.
Correct Answer: A
Rationale: Absence of bowel sounds on postoperative day 2 may indicate paralytic ileus or obstruction, a serious complication requiring immediate evaluation. Options B, C, and D are expected or normal: slight fever is common, incision pain is typical, and urine output is adequate.
The nurse is teaching a client with type 1 diabetes about insulin administration. Which of the following statements by the client indicates a need for further teaching?
- A. I should rotate injection sites to prevent tissue damage.
- B. I should store my insulin in the refrigerator.
- C. I should check my blood sugar before giving insulin.
- D. I should inject insulin into my thigh if I’m going to exercise.
Correct Answer: D
Rationale: Injecting insulin into the thigh before exercise can increase absorption due to muscle activity, risking hypoglycemia. The abdomen is preferred for consistent absorption. Options A, B, and C are correct: rotation prevents lipodystrophy, refrigeration preserves insulin, and checking blood sugar ensures proper dosing.
The nurse is teaching a client with newly diagnosed diabetes mellitus how to treat hypoglycemia at home. The nurse should instruct the client to do which of the following actions if symptoms of hypoglycemia are experienced?
- A. Eat a candy bar.
- B. Drink ½-cup fruit juice followed by a protein snack.
- C. Inject 10 units of Humulin R.
- D. Inject glucagon.
Correct Answer: B
Rationale: will correct hypoglycemia and stabilize blood sugar
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate
A 56-year-old woman has a subclavian triple lumen catheter that is used for administration of total parenteral nutrition (TPN). The physician has ordered that all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse should
- A. clamp off the lumen and label it as 'clotted off.'
- B. gradually increase the pressure on the irrigating solution.
- C. aspirate blood from the lumen to restore patency.
- D. secure the lumen with a Luer-Lock cap and notify the physician.
Correct Answer: D
Rationale: streptokinase may used to dissolve clot, if unsuccessful, lumen is labeled as clotted off