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The nurse is caring for a client who is receiving a continuous IV infusion of insulin for diabetic ketoacidosis. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 200 mg/dL.
- B. Potassium of 3.0 mEq/L.
- C. pH of 7.30.
- D. Sodium of 135 mEq/L.
Correct Answer: B
Rationale: Hypokalemia (potassium 3.0 mEq/L) is a serious complication in diabetic ketoacidosis treatment, as insulin drives potassium into cells, risking arrhythmias. Options A, C, and D are less urgent: glucose 200 mg/dL is improving, pH 7.30 is near normal, and sodium 135 mEq/L is normal.
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The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states 'I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax.' The client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Intellectualization
- D. Rationalization
Correct Answer: D
Rationale: Rationalization. The client justifies drinking by providing acceptable explanations for unacceptable behavior.
The nurse is caring for a client who is receiving heparin 5,000 units subcutaneously every 12 hours. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Platelet count of 100,000/mm^3.
- B. INR of 1.2.
- C. PTT of 40 seconds.
- D. Hemoglobin of 14 g/dL.
Correct Answer: A
Rationale: A platelet count of 100,000/mm^3 suggests thrombocytopenia, a serious complication of heparin therapy, increasing bleeding risk and possibly indicating heparin-induced thrombocytopenia. Options B, C, and D are normal or less concerning: INR and PTT are not significantly affected by subcutaneous heparin, and hemoglobin 14 g/dL is normal.
A 70-year-old man with a history of hypertension and closed-angle glaucoma visits the clinic for a routine check-up. Which of the following medications, if ordered by the physician, should the nurse question?
- A. Propranolol (Inderal), 80 mg PO QID.
- B. Verapamil (Nifedipine), 40 mg PO TID.
- C. Tetrahydrozoline (Visine), 2 gtts OU TID.
- D. Timolol (Timoptic solution), 1 gtt OU QD.
Correct Answer: C
Rationale: contraindicated; ophthalmic vasoconstrictor, contraindicated with closed angle glaucoma; use cautiously with hypertension
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
- A. I have been very careful to wash my hands after I go to the bathroom.
- B. I have had to take Tylenol several times this week for this sinus infection I have.
- C. I have been very careful not to handle my child's toys or eating utensils.
- D. My husband has been preparing all of the meals since I've been sick.
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication with meals.
- B. I should report nausea to my doctor.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping metformin when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: taking with meals reduces GI upset, nausea is a side effect, and alcohol increases lactic acidosis risk.