Nokea
The nurse is assessing a client with suspected diabetic ketoacidosis. Which finding is most expected?
- A. Kussmaul respirations
- B. Hypertension
- C. Bradycardia
- D. Clear breath sounds
Correct Answer: A
Rationale: Kussmaul respirations (rapid, deep breathing) are a compensatory mechanism in diabetic ketoacidosis to eliminate excess carbon dioxide and correct acidosis. Hypotension, tachycardia, and clear breath sounds are more common.
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To correctly assess the oxygen saturation level of an adult client, the pulse oximeter should not be placed on the:
- A. Finger
- B. Earlobe
- C. Extremity with noninvasive BP cuff
- D. Nose
Correct Answer: C
Rationale: A pulse oximeter should not be placed on an extremity with a blood pressure cuff, as cuff inflation can interrupt blood flow and cause inaccurate readings. Fingers, earlobes, and the nose are acceptable sites when circulation is adequate.
Iron dextran (Imferon) is a parenteral iron preparation. The nurse should know that it:
- A. Is also called intrinsic factor
- B. Must be given in the abdomen
- C. Requires use of the Z-track method
- D. Should be given SC
Correct Answer: C
Rationale: The Z-track method prevents staining and irritation when administering iron dextran parenterally in a large muscle.
The nurse is planning room assignments for the day. Which client should be assigned to a private room if only one is available?
- A. The client with Cushing's disease
- B. The client with diabetes
- C. The client with acromegaly
- D. The client with myxedema
Correct Answer: A
Rationale: The client with Cushing’s disease may have immune suppression due to excess cortisol, increasing infection risk. A private room minimizes exposure to pathogens. Diabetes, acromegaly, and myxedema do not typically require isolation.
The following are all nursing diagnoses appropriate for a gravida 1 para 0 in labor. Which one would be most appropriate for the primigravida as she completes the early phase of labor?
- A. Impaired gas exchange related to hyperventilation
- B. Alteration in placental perfusion related to maternal position
- C. Impaired physical mobility related to fetal-monitoring equipment
- D. Potential fluid volume deficit related to decreased fluid intake
Correct Answer: D
Rationale: In early labor primigravidas may have reduced fluid intake due to nausea or restrictions increasing the risk of fluid volume deficit. This is more common than impaired gas exchange placental perfusion issues or mobility limitations at this stage.
A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
- A. Lie prone and let her feet hang over the mattress edge
- B. Lie supine, with her feet rotated inward
- C. Lie on her right side and point her toes downward
- D. Lie on her left side and allow her feet to remain in a neutral position
Correct Answer: A
Rationale: Lying prone with feet hanging over the mattress edge helps stretch the knee joints and prevent flexion contractures in rheumatoid arthritis. The other positions do not address knee extension.