Nokea
The nurse is assessing a client with a history of diabetes mellitus who is admitted with diabetic ketoacidosis (DKA). Which of the following findings would the nurse expect?
- A. Slow, shallow respirations.
- B. Fruity breath odor.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: B
Rationale: fruity breath odor is a classic sign of DKA due to the presence of acetone
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The nurse is doing bowel and bladder retraining for the client with paraplegia. Which of the following is not a factor for the nurse to consider?
- A. Diet pattern
- B. Mobility
- C. Fluid intake
- D. Sexual function
Correct Answer: D
Rationale: Sexual function is not directly related to bowel and bladder retraining, unlike diet, mobility, and fluid intake.
The nurse is caring for a client after an open reduction to the left ulna. The client's left arm is in a plaster cast with an Ace wrap for reinforcement. Which intervention by the nurse can offer nonpharmacological comfort to this client?
- A. elevate the left arm on a pillow and apply an ice pack over the approximate location of the surgical incision
- B. call the physician and obtain an order for acetaminophen (Tylenol) 650 mg PO PRN q6 hours as needed for pain
- C. advise the client that if he starts to itch under the cast, he can use a wire coat hanger or an ink pen to gently scratch up under the cast
- D. perform range-of-motion exercises twice a shift, including bending the fingers, opening and closing the hand, and lifting the arm up to shoulder level
Correct Answer: A
Rationale: Elevation and ice reduce swelling and pain nonpharmacologically. Scratching under the cast risks skin damage, and excessive movement may disrupt healing.
A 6-month-old is hospitalized with symptoms of botulism. What aspect of the infant's history is associated with Clostridium botulinum infection?
- A. The infant sucks on his fingers and toes.
- B. The mother sweetens the infant's cereal with honey.
- C. The infant was switched to soy-based formula.
- D. The father recently purchased an aquarium.
Correct Answer: B
Rationale: Honey can contain Clostridium botulinum spores, which are a common cause of infant botulism in children under 12 months, as their digestive systems cannot eliminate the spores.
The nurse receives an order to administer 1,500 mL D5W IV over 12 hours. The drop factor is 15 drops/1 mL. The IV flow rate should be set at how many drops per minute? Round to the nearest whole number.
Correct Answer: 31
Rationale: Flow rate (drops/min) = (volume × drop factor) ÷ time. Calculation: (1,500 mL × 15 drops/mL) ÷ (12 × 60) = 22,500 ÷ 720 ≈ 31 drops/min.
The nurse should explain to a client that tolbutamide (Orinase) is effective for diabetics who
- A. can no longer produce any insulin.
- B. produce minimal amounts of insulin.
- C. are unable to administer their injections.
- D. have a sustained decreased blood glucose.
Correct Answer: B
Rationale: oral hypoglycemic agents are administered to type II (non-insulindependent) clients who are able to produce minimal amounts of insulin