Nokea
The nurse is caring for a client with pancreatitis experiencing the process of lipolysis of the pancreas. Which assessment would be a priority because of the pathophysiology of lipolysis?
- A. Checking for tetany-like movements
- B. Assessing breath sounds
- C. Obtaining vital signs
- D. Palpating pedal pulses
Correct Answer: A
Rationale: Hypocalcemia is a specific manifestation of clients with pancreatitis and lipolysis, and tetany is a major characteristic of low calcium levels. Answers B, C, and D are all pertinent assessments but are not priorities with the pathophysiology of lipolysis, so they are incorrect.
You may also like to solve these questions
The nurse is discussing dietary intake with an adolescent who has acne. The most appropriate statement for the nurse is
- A. Eat a balanced diet for your age.
- B. Increase your intake of protein and Vitamin A.
- C. Decrease fatty foods from your diet.
- D. Do not use caffeine in any form, including chocolate.
Correct Answer: A
Rationale: Eat a balanced diet for your age. There are no recommended additions and subtractions from the diet for acne management.
A newly diagnosed diabetic is learning to administer her injections of NPH and regular insulin. Which statement indicates that the client understands the nurse's teaching regarding proper insulin administration?
- A. I will administer the NPH and regular insulin in two separate injections.
- B. I will withdraw the dose of regular insulin before withdrawing the NPH insulin.
- C. It does not matter which insulin is withdrawn first as long as the amount is correct.
- D. I will withdraw the dose of NPH insulin before withdrawing the regular insulin.
Correct Answer: B
Rationale: When mixing NPH and regular insulin, regular insulin (clear) should be withdrawn first to avoid contaminating it with NPH (cloudy). Separate injections are not standard. Order matters (C is incorrect). Withdrawing NPH first risks contamination.
The nurse is providing home care to an 89-year-old man. Which comments by the client indicate a need for further follow up? Select all that apply.
- A. Excuse me if my socks don't match. I can't tell blue from green anymore.
- B. Please don't open the blinds. It hurts my eyes when the sun is bright.
- C. Let me get my reading glasses so I can read that pamphlet.
- D. I don't hear so well, but I don't want a hearing aid. I'm too old to spend that kind of money on myself.
- E. Sometimes I have to check the calendar to be sure what day it is.
- F. My grandchildren call me 'old slowpoke' because I walk slower than they do.
Correct Answer: A,B,D,E
Rationale: Color vision loss, photophobia, hearing loss, and memory issues suggest potential medical issues (e.g., cataracts, glaucoma, hearing impairment, cognitive decline) requiring follow-up.
The nurse has a pre-op order to insert a Foley catheter in a male client. The catheter should be inserted:
- A. 1-2 inches
- B. 3-4 inches
- C. 5-6 inches
- D. 7-9 inches
Correct Answer: D
Rationale: In males, a Foley catheter is inserted 7-9 inches to reach the bladder, ensuring proper placement without trauma.
The client has just had a basal cell carcinoma removed in the doctor's office. Which statement the client makes indicates understanding regarding prevention and early detection of basal cell carcinoma?
- A. Moles that are round and brown should be seen immediately by my doctor.'
- B. I should wear long sleeves when I am out in the sun.'
- C. I should avoid using lotions and powders on my skin.'
- D. I can use a tanning booth to get a tan since I can't stay in the sun very long.'
Correct Answer: B
Rationale: Long sleeves protect against UV exposure, a key risk for basal cell carcinoma. Moles, lotions, or tanning booths are unrelated or harmful.