The nurse is caring for a client who's hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 70 and 120mg/dl
- C. Between 120 and 180mg/dl
- D. Over 180mg/dl A1 PASSERS TRAINING, RESEARCH, REVIEW & DEVELOPMENT COMPANY MEDICAL SURGICAL NURSING SET P
Correct Answer: A
Rationale: Hypoglycemia is defined as a blood glucose level below 70mg/dl. When a client is experiencing hypoglycemia, it means their blood sugar is lower than the normal range and can lead to symptoms such as sweating, tremors, confusion, and even loss of consciousness. It is important for nurses to recognize and treat hypoglycemia promptly to prevent serious complications.
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Which of the following blood study results would the nurse expect as most likely when caring for the child with iron deficiency anemia?
- A. Increased hemoglobin
- B. Normal hematocrit
- C. Decreased mean corpuscular volume (MCV)
- D. Normal total iron-binding capacity (TIBC)
Correct Answer: C
Rationale: Iron deficiency anemia is characterized by a decreased mean corpuscular volume (MCV) due to the microcytic red blood cells that result from inadequate iron availability for hemoglobin synthesis. This leads to smaller red blood cells, which are reflected in a decreased MCV. Iron deficiency anemia would not typically result in an increased hemoglobin or normal hematocrit since the lack of iron impairs the production of red blood cells. Additionally, the total iron-binding capacity (TIBC) would usually be increased in iron deficiency anemia as the body attempts to compensate for the decreased iron levels by increasing its ability to bind and transport iron. Therefore, the nurse would expect a decreased mean corpuscular volume (MCV) in a child with iron deficiency anemia.
A patient is unable to control his bowels ff. a subarachnoid hemorrhage. Which intervention by the nurse can help reduce episodes of bowel incontinence?
- A. Ask the patient frequently if he has to have a bowel movement
- B. Place incontinence pads on the patient's bed and chair
- C. Toilet the patient according to his pre-illness schedule, whether or not he feels the urge
- D. Take care not to embarrass the patient when incontinent episode occur
Correct Answer: C
Rationale: Option C, which is to toilet the patient according to his pre-illness schedule, whether or not he feels the urge, is the best intervention by the nurse to help reduce episodes of bowel incontinence in this patient with subarachnoid hemorrhage. This strategy can help establish a routine and promote regular bowel movements, which may reduce the likelihood of bowel incontinence episodes. Asking the patient frequently if he has to have a bowel movement (Option A) may not be effective, as the patient may not always be able to accurately communicate their needs due to the underlying condition. Placing incontinence pads on the patient's bed and chair (Option B) may manage the consequences of incontinence but does not address the root cause. While taking care not to embarrass the patient when incontinent episodes occur (Option D) is important for maintaining the patient's dignity, it does not directly address the issue of reducing bowel incontinence episodes.
The nurse caring for a 14-year-old girl with DI understands which of the following about this disorder?
- A. DI is treated on a short-term basis with hormone replacement therapy.
- B. DI may cause anorexia if proper meal planning is not addressed.
- C. DI is treated with vasopressin on a lifelong basis.
- D. DI requires strict fluid limitation until it resolves.
Correct Answer: C
Rationale: Diabetes Insipidus (DI) is a condition characterized by the inability of the kidneys to conserve water, leading to excessive thirst and excretion of large volumes of dilute urine. Central DI, the most common form in children, is treated with a synthetic form of the hormone vasopressin, also known as desmopressin. Vasopressin helps the kidneys to retain water, thereby reducing urine output and preventing excessive dehydration. Since DI is a chronic condition, treatment with vasopressin is typically required on a lifelong basis to manage symptoms and prevent complications. It is important for healthcare providers to understand the long-term nature of DI treatment in order to provide appropriate care and support to patients with this condition.
After a Whippie procedure for cancer of the pancreas, a client is to receive the following intravenous (IV) fluids over 24 hours; 1000 ml D5W; 0.5 liter normal saline; 1500 ml D5NS. In addition, an antibiotic piggyback in 50 ml D5W is ordered every 8 hours. The nurse calculates that the clients IV fluid intake Tor 24 hours will be:
- A. 3150ml
- B. 3650 ml
- C. 3200 ml
- D. 3750ml
Correct Answer: C
Rationale: To calculate the total IV fluid intake for 24 hours, we will add up the volume of each type of fluid ordered.
All the following are recognizable teratogens EXCEPT
- A. ethanol
- B. antiepileptic medications
- C. toxoplasmosis
- D. hypothermia
Correct Answer: D
Rationale: Hypothermia is not typically considered a teratogen.