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The nurse is caring for a client who underwent a transsphenoidal hypophysectomy to remove a pituitary adenoma. Which of the following interventions should the nurse implement? Select all that apply.
- A. Encourage frequent coughing to prevent pneumonia
- B. Inspect the mouth and perform mouth care every 4 hours
- C. Maintain the head of the bed in a flat position
- D. Perform frequent neurologic checks
- E. Remind the client to avoid using a toothbrush for 10 days
Correct Answer: B,D,E
Rationale: Mouth care prevents infection, neurologic checks monitor for complications (e.g., CSF leak), and avoiding toothbrushing prevents suture disruption. Coughing risks increasing intracranial pressure, and the head of the bed should be elevated to reduce pressure.
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The nurse is reinforcing education to a group of clients who are pregnant or planning pregnancy. Which of the following client statements about alcohol use in pregnancy indicate a need for further education? Select all that apply.
- A. As long as I don't binge drink, an occasional glass of wine is fine.
- B. I drank alcohol heavily before realizing I was pregnant, so there is no benefit to quitting now.
- C. If I drink alcohol, my baby may have withdrawal after birth but no permanent damage.
- D. It is important to stop drinking while I am trying to conceive.
- E. Third-trimester alcohol use is less harmful because the baby is fully developed.
Correct Answer: A,B,C,E
Rationale: No amount of alcohol is safe during pregnancy, as it can cause fetal alcohol spectrum disorders. Quitting at any point reduces harm. Alcohol can cause permanent damage, not just withdrawal. Third-trimester exposure still risks brain development. Stopping preconception is correct.
The nurse is caring for a client who has a prescription for insulin lispro 1 unit subcutaneously per 15 g of carbohydrates with each meal. The client's meal contains 75 g of carbohydrates. How many units of insulin lispro should the nurse administer to the client? Record your answer using a whole number.
Correct Answer: 5
Rationale: 75 g carbohydrates ÷ 15 g/unit = 5 units of insulin lispro.
The nurse is caring for a client with type 1 diabetes mellitus who is reporting abdominal pain and weakness. The client has a fruity odor to the breath and rapid, deep respirations. Which of the following actions should the nurse take? Select all that apply.
- A. Instruct the client to breathe into a paper bag
- B. Check the client's capillary blood glucose level.
- C. Place the client on a continuous cardiac monitor.
- D. Prepare the client for an IV infusion of regular insulin.
- E. Gather supplies for an IV bolus of 0.9% sodium chloride
Correct Answer: B,C,D,E
Rationale: Symptoms suggest diabetic ketoacidosis (DKA). Checking glucose confirms hyperglycemia, cardiac monitoring detects arrhythmias from electrolyte imbalances, IV insulin corrects hyperglycemia, and saline bolus addresses dehydration. Breathing into a paper bag is for hyperventilation from anxiety, not DKA.
A mother has brought her 9-month-old baby to the physician's office for a well baby visit. Based on knowledge of normal growth and development, the nurse would expect that the ability the child has acquired most recently is which of the following?
- A. Sitting up unsupported
- B. Rolling over without help
- C. Holding head up without assistance
- D. Smiling in response to a familiar face
Correct Answer: A
Rationale: By 9 months, sitting unsupported is a recently acquired milestone, typically achieved around 6-8 months, following earlier skills like rolling over and head control.
The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?
- A. Teach the parents how to perform cardiopulmonary resuscitation
- B. Recommend that the parents give in when he holds his breath to prevent anoxia
- C. Advise the parents to ignore breath holding because breathing will begin as a reflex
- D. Instruct the parents on how to reason with the child about possible harmful effects
Correct Answer: C
Rationale: Advise the parents to ignore breath holding because breathing will begin as a reflex. Breath-holding is benign and self-resolving in toddlers.