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The nurse is caring for a client with a history of diabetic ketoacidosis.
- A. Which intervention is most important for a client with diabetic ketoacidosis?
- B. Administer insulin as ordered.
- C. Restrict all oral fluids.
- D. Administer oral glucose.
- E. Monitor blood pressure every 4 hours.
Correct Answer: A
Rationale: Insulin administration corrects hyperglycemia and ketosis in diabetic ketoacidosis, the primary treatment. IV fluids are used, oral glucose is contraindicated, and blood pressure monitoring is less frequent.
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Which of the following describes the proximodistal development in the infant?
- A. The infant is able to raise his head before he is able to sit.
- B. The infant can control movements of his arms before he can control movements of his fingers.
- C. The infant responds to pain with his whole body before he can localize pain.
- D. The infant is able to make rudimentary vocalizations before using spoken words.
Correct Answer: B
Rationale: Proximodistal development refers to motor control progressing from the center of the body outward, meaning infants gain control of larger muscles (arms) before finer muscles (fingers).
The nurse is caring for a client with a history of hyponatremia.
- A. Which intervention is most appropriate for a client with hyponatremia?
- B. Administer hypertonic saline slowly.
- C. Encourage a low-sodium diet.
- D. Restrict fluid intake.
- E. Administer a diuretic.
Correct Answer: A
Rationale: Administering hypertonic saline slowly corrects hyponatremia by raising serum sodium levels, preventing cerebral edema. Low-sodium diets worsen hyponatremia, fluid restriction is for hypervolemic cases, and diuretics are contraindicated.
A 48-year-old woman is seen in the outpatient clinic for complaints of irregular menses.
- A. What is the most probable cause of irregular menses in a 48-year-old woman with a history of regular periods?
- B. Emotional trauma and stress.
- C. The onset of menopause.
- D. The presence of uterine fibroids.
- E. A possible tubal pregnancy.
Correct Answer: B
Rationale: Irregular menses in a 48-year-old woman is most likely due to menopause, as ovarian function declines between ages 45- Stress lacks supporting data, fibroids cause excessive bleeding, and tubal pregnancy typically presents with missed periods and pain.
The nurse is teaching a client with a new diagnosis of rheumatoid arthritis about methotrexate (Rheumatrex). Which of the following statements by the client indicates a need for further teaching?
- A. I should avoid drinking alcohol while taking this medication.
- B. I should take this medication with food.
- C. I should report any bruising to my doctor.
- D. I should stop this medication if my joints feel better.
Correct Answer: D
Rationale: Stopping methotrexate when joints feel better is incorrect, as rheumatoid arthritis requires ongoing treatment to prevent flares. Options A, B, and C are correct: alcohol increases hepatotoxicity, food reduces GI upset, and bruising may indicate thrombocytopenia.
The nurse is teaching a school-aged child and family about the use of inhalers prescribed for asthma. What is the best way to evaluate effectiveness of the treatments?
- A. Rely on child's self-report
- B. Use a peak-flow meter
- C. Note skin color changes
- D. Monitor pulse rate
Correct Answer: B
Rationale: The peak flow meter, if used correctly, shows effectiveness of inhalants.