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The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin glargine (Lantus) 20 units at bedtime. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue in the morning.
- B. Sweating and shakiness at night.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin. Options A, C, and D are less urgent.
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An adult who is on an American Dietetic Association (ADA) diabetic diet tells the nurse that she will not eat the asparagus that is on her tray. What would be an appropriate substitute for the nurse to offer?
- A. Broccoli
- B. Corn
- C. Peas
- D. Beets
Correct Answer: A
Rationale: Broccoli, like asparagus, is a non-starchy vegetable, fitting the ADA diabetic diet's emphasis on low-glycemic foods. Corn, peas, and beets are higher in carbohydrates.
Which diet selection contains the most potassium and should be removed from the tray of the client with renal failure?
- A. Peach
- B. Baked potato
- C. Marshmallows
- D. Bread
Correct Answer: B
Rationale: Baked potatoes are high in potassium, which is restricted in renal failure to prevent hyperkalemia. Peach , marshmallows , and bread have lower potassium content.
A client in labor is receiving magnesium sulfate IV.
Which assessment is MOST important to give during report to the nurse on the next shift?
- A. Respiratory rate changed from 13/min to 15/min.
- B. Increase in anxiety and hyperactivity.
- C. Presence of nausea and refusal to take clear liquids.
- D. Urine output decreased from 60 cc/h to 40 cc/h.
Correct Answer: D
Rationale: Strategy: Determine how each answer choice relates to magnesium sulfate. (1) not a concern because the respirations are increasing (2) not relevant to the medication (3) not relevant to the medication (4) correct-magnesium sulfate is a central nervous system depressant; side effect is oliguria
A client is scheduled for electromyography (EMG).
What should the nurse tell the client about the procedure?
- A. Your hair will be carefully washed prior to the procedure.'
- B. This is a noninvasive procedure that takes about 30 minutes.'
- C. A sedative will be given to you shortly before the procedure.'
- D. You will not be allowed to eat 4-6 hours before the procedure.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) usually performed on the legs (2) correct-electrodes are attached to legs, length of time for impulse transmission is measured (3) may impair Test results (4) doesn't involve general anesthesia or GI system
The nurse is caring for a client with organic brain syndrome in a long-term care facility.
Which of the following actions by the nurse is BEST?
- A. Encourage the client to verbalize his feelings regarding the relationship with his family that initiated his nursing home placement.
- B. Help the client to express his favorite pastimes and the type of activities that he enjoys.
- C. Orient the client to the present time and assist him to be alert and oriented when his family comes to visit.
- D. Direct conversation toward assisting the client to reminisce and talk about important past events in his life.
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) may not remember who or where he is (2) not as important as answer choice #4 (3) even with orientation, the client soon forgets (4) correct-geriatric client should be encouraged to talk about his life and important things in the past because he has recent memory loss