Nokea
The nurse is caring for the client diagnosed with DI. Which nursing actions are most appropriate? Select all that apply.
- A. Monitoring hourly urine output and daily weights
- B. Checking urine osmolality and urine ketones
- C. Giving desmopressin acetate (DDAVP) as prescribed
- D. Checking glucose levels before meals and at bedtime
- E. Monitoring for signs or symptoms of hyperkalemia
Correct Answer: A,C
Rationale: Monitoring urine output and weights tracks fluid loss, and DDAVP replaces ADH in DI.
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The nurse is caring for the client who had a thyroidectomy 2 days ago. Based on the findings of the client's serum laboratory report, which medication should the nurse plan to administer first?
- A. Potassium chloride 20 mEq oral bid
- B. Calcium gluconate 4.5 mEq IV once
- C. Dolasetron 12.5 mg IV as needed
- D. Levothyroxine 50 mcg oral daily
Correct Answer: B
Rationale: The serum calcium is critically low (6 mg/dL). Calcium gluconate addresses hypocalcemia from parathyroid gland damage during thyroidectomy.
An adolescent with newly diagnosed Type I diabetes mellitus asks the nurse if he can continue to play football. What is the best answer for the nurse to give?
- A. Now that you have diabetes, you should not play football because you may get a cut that will not heal.'
- B. If you work with your physician to regulate the insulin dosage and your diet, you should be able to play football.'
- C. It would be better for you to work as equipment manager so you will not be under as much stress.'
- D. You can probably continue to play football if you can regulate it so that you have the same amount of exercise each day.'
Correct Answer: B
Rationale: With proper insulin and diet management, the adolescent can safely play football, supporting physical activity and normalcy.
The client is immediate postprocedure endoscopic retrograde cholangiopancreatogram (ERCP). Which intervention should the nurse implement?
- A. Assess for rectal bleeding.
- B. Increase fluid intake.
- C. Assess gag reflex.
- D. Keep in supine position.
Correct Answer: C
Rationale: ERCP involves throat anesthesia; assessing the gag reflex ensures safe swallowing post-procedure. Rectal bleeding, fluids, and supine positioning are irrelevant.
The nurse is teaching a client to self-administer insulin. The instructions should include teaching the client to:
- A. inject the needle at a 90-degree angle into the muscle.
- B. vigorously massage the area after injecting the insulin.
- C. rotate injection sites.
- D. keep the open bottle of insulin in the refrigerator.
Correct Answer: C
Rationale: Rotating injection sites prevents lipodystrophy and ensures consistent insulin absorption. Insulin is injected subcutaneously, not into muscle, and massaging can alter absorption.
The diabetic client tells the nurse that breakfast is always skipped. Which response by the nurse is most appropriate?
- A. If you drink a glass of milk and eat a breakfast bar, that will be sufficient for breakfast.
- B. You should eat each meal and snack at the same time each day.
- C. If you skip breakfast, eat a high-calorie snack at midmorning.
- D. Wait to take your medication until you eat your first meal of the day.
Correct Answer: B
Rationale: Consistent meal timing is crucial for blood glucose control in diabetes.