Nokea
The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 90 mg/dL.
- B. Heart rate of 80 bpm.
- C. Sweating and confusion.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: C
Rationale: Sweating and confusion indicate hypoglycemia, a serious complication of insulin lispro, requiring immediate treatment with carbohydrates. Options A, B, and D are normal: glucose 90 mg/dL, heart rate 80 bpm, and blood pressure 120/80 mmHg indicate stability.
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A 34-year-old man comes to the clinic for the results of a glycosylated hemoglobin assay (HbA1c). Which statement, if made by the client to the nurse, indicates an understanding of this procedure?
- A. This Test is performed by sticking my finger and measuring the results.
- B. This Test needs to be performed in the morning before I eat breakfast.
- C. This Test indicates how well my blood sugar has been controlled the past 6-8 weeks.
- D. I must follow my diet carefully for several days before the Test .
Correct Answer: C
Rationale: when RBCs are being formed, sugar is attached (glycosylated) and remains attached throughout the life of the RBC
A comatose patient who is incontinent.
The nurse should intervene if which of the following actions is noted?
- A. The nurse assistant answers the phone while wearing gloves.
- B. The nursing assistant log rolls the patient to provide back care.
- C. The nursing assistant places an incontinence pad under the patient.
- D. The nursing assistant positions the patient on the left side, head elevated.
Correct Answer: A
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) correct-contaminated gloves should be removed before answering the phone (2) correct way to roll a patient to maintain proper alignment (3) appropriate to use incontinence pad for this patient (4) appropriate position to prevent aspiration and protect the airway
The nurse is caring for a client in the outpatient clinic who is four months pregnant.
- A. Which symptom reported by a four-month pregnant client requires immediate follow-up?
- B. Intermittent nausea in the morning.
- C. A white vaginal discharge.
- D. Breast tenderness bilaterally.
- E. Feeling the need to void more frequently.
Correct Answer: A
Rationale: Intermittent nausea in the second trimester (four months) is abnormal, as morning sickness typically resolves by the end of the first trimester, and may indicate complications like hyperemesis gravidarum or other issues requiring evaluation. Vaginal discharge, breast tenderness, and frequent urination are normal pregnancy symptoms.
The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should:
- A. confront the staff member immediately and say, 'You know that is not the treatment plan.'
- B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
- C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
- D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.
Correct Answer: C
Rationale: It is essential that the treatment program be followed exactly for clients with antisocial personality disorder because they are very manipulative and attempt to divide staff. However, confronting the staff member in front of the client enhances the division of staff.
An adult has recently been diagnosed with chronic obstructive pulmonary disease (COPD). All of the following goals are in the teaching plan. Which will probably be most difficult for the client to achieve?
- A. Stop smoking within three months
- B. Demonstrate pursed lip breathing technique within one week
- C. Drink 2 L of fluid each day
- D. Receive vaccinations against flu and pneumonia within one month
Correct Answer: A
Rationale: Smoking cessation is the most challenging due to nicotine addiction, despite being critical for COPD management, compared to learning breathing techniques, hydration, or vaccinations.