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The nurse is caring for a client with diabetic ketoacidosis (DKA) who is receiving an infusion of regular insulin. Which of the following clinical data should be reported to the primary healthcare provider (PHCP) immediately?
- A. Glucose 297 mg/dL, 16.52 mmol/L (70-110 mg/dL, 4.0-11.0 mmol/L)
- B. Potassium 3.2 mEq/L, 3.2 mmol/L (3.5-5 mEq/L, 3.5-5.1 mmol/L)
- C. BUN 24 mg/dL, 8.568 mmol/L (10-20 mg/dL, 2.5 to 6.4 mmol/L)
- D. Hemoglobin A1C 8.9% ( < 7%, 4.8%-6.0%)
Correct Answer: B
Rationale: In DKA, insulin shifts potassium into cells, risking hypokalemia. A level of 3.2 mEq/L is critical and needs immediate reporting to prevent arrhythmias. Glucose, BUN, and HbA1C are monitored but less urgent.
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The nurse is caring for a client who has adrenal insufficiency (Addison's disease). Which of the following interventions would be a priority?
- A. Administer prescribed hydrocortisone
- B. Offer salty snacks and water
- C. Assess skin integrity
- D. Encourage frequent rest periods
Correct Answer: A
Rationale: Adrenal insufficiency causes cortisol deficiency, leading to hypotension and weakness. Administering hydrocortisone is critical to replace cortisol and stabilize the client. Salty snacks, skin checks, and rest are supportive but not the priority.
The nurse is planning a staff education program about conditions that increase cortisol levels. Which of the following conditions should the nurse include?
- A. Addison's disease
- B. Congestive heart failure (CHF)
- C. Renal failure
- D. Cushing's disease
Correct Answer: D
Rationale: Cushing's disease increases cortisol due to excess ACTH. Addison's reduces cortisol, and CHF and renal failure do not directly elevate cortisol levels.
The nurse is preparing to administer a regular insulin IV bolus to a client. The primary health care provider (PHCP) has prescribed an initial bolus dose of 0.1 unit/kg. The client weighs 242 lbs. How much regular insulin should the nurse administer to the client as an IV bolus?
Correct Answer: 11
Rationale: Convert 242 lbs to kg: 242 ÷ 2.2 = 110 kg. Calculate dose: 110 kg × 0.1 unit/kg = 11 units. Thus, 11 units of regular insulin should be administered.
The nurse is caring for a client suspected of having an endocrine disorder. Based on the client's laboratory data, the nurse is at the highest risk for which condition? See the exhibit.
- A. syndrome of inappropriate antidiuretic hormone (SIADH)
- B. diabetes insipidus (DI)
- C. cushing's syndrome/disease
- D. adrenal insufficiency
Correct Answer: C
Rationale: Without specific lab data, Cushing's is a common suspect in endocrine disorders with weight gain, hyperglycemia, and hypertension. SIADH, DI, and adrenal insufficiency require specific lab patterns (e.g., sodium, urine output).
The nurse is caring for a client with Graves' disease who has exophthalmos. The nurse should recommend that the client
- A. prevent eye dryness by applying artificial tears.
- B. use scanning techniques to move the head from side to side.
- C. take their thyroid hormone as prescribed.
- D. sleep flat on your back without any pillows.
Correct Answer: A
Rationale: Exophthalmos in Graves' disease causes protruding eyes, increasing the risk of dryness and irritation. Artificial tears help maintain moisture and protect the eyes. Sleeping flat may worsen eye protrusion, and thyroid hormone management is unrelated to exophthalmos directly.