Nokea
The nurse is assisting with the care of a client who has diabetic ketoacidosis. The nurse should recognize that it is a priority to
- A. gather supplies for an IV bolus of 0.9% sodium chloride
- B. prepare the client for an IV infusion of regular insulin
- C. request a prescription for potassium chloride
- D. obtain a urine specimen for urinalysis
Correct Answer: B
Rationale: In diabetic ketoacidosis, insulin administration is the priority to correct hyperglycemia and halt ketogenesis, addressing the underlying metabolic crisis.
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The nurse is reinforcing teaching to an overweight 54-year-old client about ways to decrease symptoms of obstructive sleep apnea. Which interventions would be most effective? Select all that apply.
- A. Eating a high-protein snack at bedtime
- B. Limiting alcohol intake
- C. Losing weight
- D. Taking a mild sedative at bedtime
- E. Taking a nap during the day
- F. Taking modafinil at bedtime
Correct Answer: B,C
Rationale: Limiting alcohol (B) reduces airway relaxation, and losing weight (C) decreases airway obstruction, both directly alleviating sleep apnea symptoms.
The client has been vomiting for several days. Which blood gas values is he likely to have?
- A. pH=7.32; CO2=60; HCO3=30
- B. pH=7.32; CO2=33; HCO3=18
- C. pH=7.54; CO2=28; HCO3=22
- D. pH=7.54; CO2=32; HCO3=34
Correct Answer: C
Rationale: Prolonged vomiting causes metabolic alkalosis (high pH, low CO2) due to loss of stomach acid, matching pH=7.54, CO2=28, HCO3=22.
A client has an order for 1000 ml of D5W over an 8 hour period. The nurse discovers that 800 ml has been infused after 4 hours. What is the priority nursing action?
- A. Ask the client if there are any breathing problems
- B. Have the client void as much as possible
- C. Check the vital signs
- D. Auscultate the lungs
Correct Answer: D
Rationale: All of the options would be part of the evaluation for the effects of the large amount of fluid in a short period of time. However, the worst result is heart failure with lung congestion, so the auscultation of the lungs is the priority action.
Following a typanoplasty, the nurse should maintain the client in which position?
- A. Semi-Fowler's with the operative ear facing down
- B. Low Trendelenburg with the head in neutral position
- C. Flat with the head turned to the side with the operative ear facing up
- D. Supine with a small neck roll to allow for drainage
Correct Answer: C
Rationale: After tympanoplasty, the client should be positioned flat with the head turned to the side and the operative ear facing up to promote healing and prevent pressure on the surgical site. Answer A is incorrect because the operative ear should face up, not down. Answer B is incorrect because low Trendelenburg is not indicated. Answer D is incorrect because a neck roll may not ensure proper positioning of the operative ear.
The nurse is collecting data from a 30-month-old client. Which of the following findings would require follow-up?
- A. head circumference has increased by 1 inch (2.5 cm) in the past year
- B. current weight is six times greater than birth weight
- C. nighttime bladder control has not been achieved
- D. anterior and posterior fontanels are both fused
Correct Answer: C
Rationale: Lack of nighttime bladder control at 30 months may indicate developmental delay or medical issues, requiring follow-up to assess for underlying causes.