Nokea
The nurse is caring for a client with diabetic ketoacidosis (DKA). Which of the following acid-base imbalances would the nurse expect to assess in this client?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: DKA causes metabolic acidosis due to excess ketone production from fat breakdown. Alkalosis and respiratory imbalances are not typical in DKA.
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Magnetic resonance imaging has been ordered for a client. Which factor should the nurse report to the physician?
- A. The client states she had an allergic reaction to iodine.
- B. The client has a pacemaker.
- C. The client wears a hearing aid.
- D. The client takes digoxin.
Correct Answer: B
Rationale: A pacemaker is a contraindication for MRI due to magnetic interference, requiring immediate physician notification to ensure safety.
A client newly returned to the unit after knee surgery asks the nurse for assistance to a chair. What action should the nurse implement first?
- A. Ask another nurse to help
- B. Delegate the task to unlicensed assistive personnel
- C. Premedicate the client for pain
- D. Verify the client's activity prescription
Correct Answer: D
Rationale: Verifying the activity prescription ensures the client is cleared for chair transfer, preventing injury. Assistance, delegation, or premedication are secondary until safety is confirmed.
The nurse is caring for several 70 to 80 year-old clients on bed rest. What is the most important measure to prevent skin breakdown?
- A. Massage legs frequently
- B. Frequent turning
- C. Moisten skin with lotions
- D. Apply moist heat to reddened areas
Correct Answer: B
Rationale: Frequent turning. Frequent turning will prevent skin breakdown by relieving prolonged pressure on any one area.
The nurse is preparing to administer preoperative medication of meperidine and atropine to an elderly adult who is scheduled for surgery. The client tells the nurse that he has glaucoma and wants to take his eye drops before going to the operating room. What is the best action for the nurse to take?
- A. Administer medication as ordered and encourage the client to take his eye drops
- B. Check with the physician before administering preoperative medication
- C. Administer preoperative medication as ordered and suggest the client not take his eye drops
- D. Administer the meperidine, withhold atropine, and suggest the client take his eye drops
Correct Answer: B
Rationale: Atropine, an anticholinergic, can increase intraocular pressure, exacerbating glaucoma. Checking with the physician ensures safe administration, as withholding atropine or adjusting eye drop use may be necessary.
An adult has both an oil retention enema and a cleansing enema ordered. The nurse knows that this client is most likely to have which condition/ problem?
- A. Straining while defecating
- B. Melena
- C. Ulcerative colitis
- D. Fecal impaction
Correct Answer: D
Rationale: Oil retention enemas soften hardened stool, and cleansing enemas remove it, making this combination most appropriate for fecal impaction. Straining, melena, or ulcerative colitis are less likely to require both types of enemas.