Nokea
The nurse identified a concept of metabolism for a client diagnosed with diabetes mellitus type 2. Which interventions should the nurse include in the plan of care? Select all that apply.
- A. Teach the client to perform self glucose monitoring.
- B. Instruct the client about complications of high-glucose levels.
- C. Instruct the client to inspect the feet daily.
- D. Explain the need to carry a source of quick-acting proteins.
- E. Encourage the client to have regular eye exams.
Correct Answer: A,B,C,E
Rationale: Glucose monitoring, complication education, foot inspections, and eye exams manage type 2 diabetes and prevent complications. Quick-acting proteins are incorrect; carbohydrates treat hypoglycemia.
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Which client problem has priority for the client diagnosed with acute pancreatitis?
- A. Risk for fluid volume deficit.
- B. Alteration in comfort.
- C. Imbalanced nutrition: less than body requirements.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in acute pancreatitis due to vomiting and third-spacing, risking hypovolemia. Pain, nutrition, and knowledge are secondary.
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.
The nurse is caring for the client with Addisonian crisis. Which clinical change should indicate to the nurse that the therapy is effective?
- A. Increase of 25 mm Hg in the client's blood pressure
- B. Decrease of 25 mm Hg in the systolic blood pressure
- C. Increase in serum potassium from 3.4 to 5.8 mEq/dL
- D. Decrease in serum sodium from 146 to 136 mEq/L
Correct Answer: A
Rationale: An increase in BP indicates effective therapy by correcting hypotension from sodium and water depletion.
Which action is the best indication that the client needs more practice in combining two insulins in one syringe?
- A. The client rolls the vial of intermediate-acting insulin to mix it with its additive.
- B. The client still have a little or less the fast-acting and intermediate-acting insulin vials.
- C. The client instills the intermediate-acting insulin into the vial of rapid-acting insulin.
- D. The client inverts each vial before withdrawing the specified amount of insulin.
Correct Answer: C
Rationale: Instilling insulin into another vial contaminates the medication and is incorrect.
Which signs/symptoms indicate the client with hypothyroidism is not taking enough thyroid hormone?
- A. Complaints of weight loss and fine tremors.
- B. Complaints of excessive thirst and urination.
- C. Complaints of constipation and being cold.
- D. Complaints of delayed wound healing and belching.
Correct Answer: C
Rationale: Constipation and cold intolerance indicate persistent hypothyroidism due to inadequate thyroid hormone. Weight loss/tremors, thirst, and healing/belching are unrelated.