Nokea
The nurse is caring for a client with hyperosmolar hyperglycemic state (HHS). The nurse should recognize which characteristic is most consistent with HHS?
- A. Abdominal pain
- B. Altered level of consciousness
- C. History of type 1 diabetes
- D. Kussmaul respirations
Correct Answer: B
Rationale: Altered consciousness (B) is a hallmark of HHS due to severe hyperglycemia and dehydration. Abdominal pain (A) and Kussmaul respirations (D) are more typical of DKA, and HHS is associated with type 2 diabetes (C).
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The nurse is reviewing laboratory test results for an 80-year-old client who has a methicillin-resistant Staphylococcus aureus infection and is receiving vancomycin. Which of the following test results would require immediate follow-up?
- A. elevated BUN
- B. decreased serum iron level
- C. decreased serum triglyceride level
- D. elevated capillary blood glucose level
Correct Answer: A
Rationale: Elevated BUN (A) may indicate nephrotoxicity, a serious side effect of vancomycin requiring immediate follow-up. Decreased iron (B) or triglycerides (C) are not directly related to vancomycin toxicity. Elevated glucose (D) may need monitoring but is less urgent.
Which test for diabetes measures the long-term management of the disease?
- A. Fasting blood sugar
- B. Glucose tolerance test
- C. Finger stick glucose test
- D. Glycosylated hemoglobin
Correct Answer: D
Rationale: Glycosylated hemoglobin (HbA1c) measures average blood glucose over 2-3 months, assessing long-term diabetes control, unlike fasting, tolerance, or finger stick tests, which are short-term.
A client diagnosed with hypertension has been prescribed a clonidine patch. Which instructions should the nurse include to reinforce prior teaching? Select all that apply.
- A. Apply patch to the upper arm or chest
- B. Fold used patches in half with sticky sides together before discarding
- C. Remove patch if dizziness occurs when getting up
- D. Rotate sites each time a new patch is applied
- E. Shave hair before applying patch
Correct Answer: A, B, D
Rationale: Applying to upper arm/chest (A), folding patches (B), and rotating sites (D) ensure safe use. Removing for dizziness (C) requires medical consultation, and shaving (E) can irritate skin.
The nurse is caring for a client who has a prescription for ampicillin 1.5 g IV in 100 mL of 0.9% sodium chloride to be administered over 30 minutes. The nurse has tubing with a drop factor of 15 available. How many gtts/min should the client receive? Record your answer using a whole number.
Correct Answer: 50
Rationale: Flow rate = (100 mL / 30 min) x (15 gtts/mL) = 50 gtts/min (A).
The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse
- A. verifies that gel is present on each electrode and is not dried out
- B. cleanses and dries the skin before placing the electrodes on the client
- C. clips excessive hair off the client before applying the electrodes
- D. places one electrode each on the client's upper and lower extremities
Correct Answer: D
Rationale: Placing electrodes on extremities (D) is incorrect for cardiac monitoring, which requires chest placement. Verifying gel (A), cleansing skin (B), and clipping hair (C) are appropriate.