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The nurse is caring for a client who’s hypoglycemic. This client will have a blood glucose level:
- A. Below 70mg/dl
- B. Between 120 and 180mg/dl
- C. Between 70 and 120mg/dl
- D. Over 180mg/dl
Correct Answer: A
Rationale: The correct answer is A: Below 70mg/dl. Hypoglycemia is defined as a blood glucose level below 70mg/dl. Symptoms of hypoglycemia include confusion, shakiness, and sweating. Treating hypoglycemia involves administering fast-acting carbohydrates. Choices B, C, and D are incorrect because they describe blood glucose levels that are within the normal or hyperglycemic range, which are not indicative of hypoglycemia. It is essential for the nurse to recognize and promptly address hypoglycemia to prevent serious complications.
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A patient asks the nurse what is CYSTOCLYSIS? The best explanation would be:
- A. to increase bladder atony
- B. to maintain patency of the foley
- C. to remove blood clots from the bladder catheter
- D. to lower the specific gravity of the urine
Correct Answer: B
Rationale: Rationale:
B is correct because cystoclisis is the process of maintaining patency of a foley catheter by irrigating it with a sterile solution. This prevents blockages and promotes proper drainage.
A, C, and D are incorrect because cystoclisis is not related to increasing bladder atony, removing blood clots, or altering urine specific gravity.
Which assessment action will help the nurse determine if the patient with Bell’s Palsy is receiving adequate nutrition?
- A. Monitor meal trays
- B. Check twice-weekly weights
- C. Measure intake and output
- D. Assess swallowing reflex
Correct Answer: D
Rationale: The correct answer is D: Assess swallowing reflex. This is crucial for a patient with Bell's Palsy as it can affect their ability to swallow properly, leading to inadequate nutrition intake. By assessing the swallowing reflex, the nurse can determine if the patient is at risk of aspiration or difficulty in eating, which directly impacts their nutrition status. Monitoring meal trays (A) may not provide accurate information on actual food intake. Checking weights (B) only gives limited information on nutrition status. Measuring intake and output (C) is important for fluid balance but may not directly reflect adequate nutrition intake.
Before administering a food feeding the nurse knows to perform which of the following assessments/
- A. The GI tract, including bowel sounds, last BM, and distention
- B. The client’s neurologic status, especially the gag reflex
- C. The amount of air in the stomach
- D. That the formula is used directly from the refrigerator
Correct Answer: A
Rationale: The correct answer is A because assessing the GI tract helps determine the client's readiness for feeding. Bowel sounds indicate gut motility, last BM assesses bowel function, and distention indicates possible issues. Option B is incorrect as it pertains more to neurological assessment. Option C is not a priority assessment before feeding. Option D is incorrect as formula should be warmed to room temperature before feeding to prevent GI upset.
Blood and fluid loss from frequent diarrhea may cause hypovolemia and you can quickly assess volume depletion in Miss CC by:
- A. Measuring the quantity and specific gravity of her urine output
- B. Taking her blood pressure
- C. Comparing the patient’s present weight with her last weight
- D. Administering the oral water test
Correct Answer: C
Rationale: The correct answer is C: Comparing the patient’s present weight with her last weight. This is the most direct and reliable method to assess volume depletion due to fluid loss. By comparing the patient's current weight with her last weight, you can easily determine if there has been a significant decrease in weight indicating fluid loss and potential hypovolemia.
Explanation of why other choices are incorrect:
A: Measuring the quantity and specific gravity of her urine output - This method may provide some information about hydration status, but it is not as direct or reliable as comparing weight changes.
B: Taking her blood pressure - While blood pressure can indicate hypovolemia, it may not provide immediate insight into volume depletion caused by diarrhea.
D: Administering the oral water test - This test is not commonly used to assess volume depletion and may not be as effective or quick as comparing weight changes.
A patient is admitted with symptoms of a recent weight gain, 3+ pitting edema of his feet, distended neck veins, and crackles in his lungs. Which of the following nursing diagnoses is most appropriate for this patient’s plan of care?
- A. Deficient fluid volume
- B. Imbalanced nutrition more than body requirements
- C. Excess fluid volume
- D. Noncompliance
Correct Answer: C
Rationale: The correct answer is C: Excess fluid volume. This patient is presenting with signs and symptoms of fluid overload, such as weight gain, pitting edema, distended neck veins, and crackles in the lungs. These indicate an excess of fluid in the body. Nursing care for this patient should focus on managing fluid balance.
A: Deficient fluid volume is incorrect because the patient is showing signs of fluid overload, not deficit.
B: Imbalanced nutrition more than body requirements is incorrect as the symptoms described are related to fluid volume, not nutrition intake.
D: Noncompliance is irrelevant to the patient's current symptoms and does not address the underlying issue of fluid overload.