Nokea
The nurse is caring for multiple clients with DM. It is most important for the nurse to initiate a referral to a diabetes educator for which client?
- A. The client who states diabetes is well controlled with diet and exercise; Hgb A1c is 11%.
- B. The client requesting diabetes information; fingerstick glucose is 132 mg/dL, Hgb A1c is 5.6%.
- C. The client who states perfect compliance with diet, exercise, and meds; Hgb A1c is 7%.
- D. The client with short-term memory loss; fingerstick glucose is 110 mg/dL, Hgb A1c is 4.5%.
Correct Answer: A
Rationale: It is most important for the nurse to initiate a referral for clients who falsely think their diabetes is well controlled. The client's Hgb A1c, which measures average blood glucose over the previous 3 months, is 11%, indicating that the diabetes is not well controlled.
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A woman with hypothyroidism asks the nurse why the doctor told her she cannot have a sedative. The nurse's response is based on which of the following facts?
- A. Sedatives potentiate thyroid replacement medication.
- B. Clients with hypothyroidism have increased susceptibility to all sedative drugs.
- C. Sedatives will have a paradoxical effect on clients with hypothyroidism.
- D. Sedatives would cause fluid retention and hypernatremia.
Correct Answer: B
Rationale: Hypothyroidism increases sensitivity to sedatives, risking excessive sedation or respiratory depression.
The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first?
- A. Tell the UAP to fill the pitcher with ice cold water.
- B. Instruct the UAP to start measuring the client's I&O.
- C. Assess the client for polyuria and polydipsia.
- D. Check the client's BUN and creatinine levels.
Correct Answer: C
Rationale: Frequent water pitcher refills suggest polydipsia and polyuria, symptoms of diabetes insipidus post-head injury, requiring assessment. I&O, labs, and refilling follow.
The client received 10 units of Humulin R, a fast-acting insulin, at 0700. At 1030 the unlicensed assistive personnel (UAP) tells the nurse the client has a headache and is really acting 'funny.' Which intervention should the nurse implement first?
- A. Instruct the UAP to obtain the blood glucose level.
- B. Have the client drink eight (8) ounces of orange juice.
- C. Go to the client's room and assess the client for hypoglycemia.
- D. Prepare to administer one (1) ampule 50% dextrose intravenously.
Correct Answer: C
Rationale: Assessing for hypoglycemia (e.g., confusion, headache) confirms the cause, as Humulin R peaks around 3 hours. UAPs cannot check glucose, and treatment follows confirmation.
When the client asks how to store an opened vial of insulin, which answer by the nurse offers the most correct instruction?
- A. The best place for storing insulin is in the bathroom, close to the shower.
- B. The best place to store insulin is in the refrigerator.
- C. The best way to store insulin is at room temperature.
- D. The best place for storing insulin is in a warm location but out of sunlight.
Correct Answer: C
Rationale: Opened insulin vials can be stored at room temperature for up to 28 days for stability and comfort during injection.
Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU?
- A. Glucose.
- B. Potassium.
- C. Calcium.
- D. Sodium.
Correct Answer: B
Rationale: DKA causes potassium depletion due to acidosis and diuresis; replacement is anticipated to prevent arrhythmias. Glucose is not an electrolyte, and calcium/sodium are less critical.