Nokea
The nurse is admitting the client tentatively diagnosed with possible hyperaldosteronism. What should be the nurse's priority?
- A. Prepare for a computed tomography (CT) scan
- B. Give prn prescribed analgesic to treat headache
- C. Obtain an ECG to evaluate for dysrhythmias
- D. Assess for generalized weakness and fatigue
Correct Answer: C
Rationale: Obtaining an ECG is priority to detect dysrhythmias from hypokalemia caused by potassium wasting in hyperaldosteronism.
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The nurse is preparing to administer a.m. medications to clients. Which medication should the nurse question before administering?
- A. Pancreatic enzymes to the client who has finished breakfast.
- B. The pain medication, morphine, to the client who has a respiratory rate of 20.
- C. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L.
- D. The beta blocker to the client who has an apical pulse of 68 bpm.
Correct Answer: A
Rationale: Pancreatic enzymes should be taken with meals, not after, to aid digestion. Morphine, diuretics, and beta blockers are appropriate based on the data.
The nurse is caring for the client diagnosed with DI. Which nursing actions are most appropriate? Select all that apply.
- A. Monitoring hourly urine output and daily weights
- B. Checking urine osmolality and urine ketones
- C. Giving desmopressin acetate (DDAVP) as prescribed
- D. Checking glucose levels before meals and at bedtime
- E. Monitoring for signs or symptoms of hyperkalemia
Correct Answer: A,C
Rationale: Monitoring urine output and weights tracks fluid loss, and DDAVP replaces ADH in DI.
The nurse is assessing the client who has type 2 DM. Which findings indicate to the nurse that the client is experiencing HHNS? Select all that apply.
- A. Serum osmolality 364 mOsm/kg
- B. Blood glucose level 160 mg/dL
- C. Very dry mucous membranes
- D. Blood pressure of 90/42 mm Hg
- E. Urine output 500 mL past 8 hours
Correct Answer: A,C,D
Rationale: A serum osmolality of 364 mOsm/kg, very dry mucous membranes, and a BP of 90/42 indicate HHNS due to elevated osmolality, dehydration, and hypotension from osmotic diuresis.
If a regular diet is ordered, which between-meal snack should the nurse offer to help regulate the client's blood glucose level?
- A. A small carton of milk
- B. A small apple
- C. A handful of raisins
- D. A slice of bread
Correct Answer: A
Rationale: A small carton of milk provides a balance of carbohydrates and protein to stabilize blood glucose in hypoglycemia.
Which instruction should the nurse give the client about insulin administration during periods of illness?
- A. Monitor blood glucose levels every 2 to 4 hours.
- B. Eat candy or sugar frequently.
- C. Attempt to drink a high-calorie beverage every hour.
- D. Test urine daily for protein.
Correct Answer: A
Rationale: Frequent blood glucose monitoring during illness helps adjust insulin doses to prevent complications.