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The nurse is caring for a client with a history of type 2 diabetes who is receiving insulin aspart (NovoLog) 10 units subcutaneously before meals. Which of the following findings would be of GREATest concern to the nurse?
- A. Blood glucose of 80 mg/dL.
- B. Heart rate of 90 bpm.
- C. Sweating and shakiness.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: C
Rationale: Sweating and shakiness indicate hypoglycemia, a serious complication of insulin aspart, requiring immediate treatment with carbohydrates. Options A, B, and D are less concerning: glucose 80 mg/dL is normal, heart rate 90 bpm and blood pressure 130/80 mmHg are stable.
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To prevent symptoms of Raynaud's, the client should:
- A. Avoid a high-sodium diet
- B. Take a brisk, 15-minute walk daily
- C. Avoid exposure to cold
- D. Increase her vitamin C intake
Correct Answer: C
Rationale: Avoiding cold exposure is key to preventing vasospasms in Raynaud's disease, which cause symptoms like numbness and color changes in the extremities.
The nurse is teaching childbirth preparation classes. One woman asks about her rights to develop a birthing plan. Which response made by the nurse would be best?
- A. What is your reason for wanting such a plan?
- B. Have you talked with your provider about this?
- C. Let us discuss your rights as a couple
- D. Write your ideal plan for the next class
Correct Answer: C
Rationale: Discussion of the provider's role and the couple's rights and limitations in selecting birth options must precede development of a plan.
The nurse manager identifies that time spent by staff in charting is excessive, requiring overtime for completion. The nurse manager states that 'staff will form a task force to investigate and develop potential solutions to the problem, and report on this at the next staff meeting.' The nurse manager's leadership style is best described as
- A. Laissez-faire
- B. Autocratic
- C. Participative
- D. Group
Correct Answer: C
Rationale: Participative. A participative style of management involves staff in decision-making processes. Staff/manager interactions are open and trusting. Most work efforts are joint endeavors.
An adult is admitted with probable pulmonary tuberculosis. Which findings would the nurse expect to be present in this client? Select all that apply.
- A. High fevers in the morning
- B. Cough
- C. Bloody sputum
- D. Night sweats
- E. Weight gain
- F. Malaise
Correct Answer: B,C,D,F
Rationale: Tuberculosis causes chronic cough, hemoptysis (bloody sputum), night sweats, and malaise due to systemic infection. Fevers are typically low-grade and nocturnal, and weight loss, not gain, is common.
Included in teaching the client with tuberculosis taking isoniazid (INH) about follow-up home care, the nurse should emphasize that a laboratory appointment for which of the following lab tests is critical?
- A. Liver function
- B. Kidney function
- C. Blood sugar
- D. Cardiac enzymes
Correct Answer: A
Rationale: Liver function. INH can cause hepatocellular injury and hepatitis. This side effect is age-related and can be detected with regular assessment of liver enzymes, which are released into the blood from damaged liver cells.