The nurse is caring for the client diagnosed with DI. Which...

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 assessing the client who has type 2 DM. Which findings indicate to the nurse that the client is experiencing HHNS? Select all that apply.

A. Serum osmolality 364 mOsm/kg
B. Blood glucose level 160 mg/dL
C. Very dry mucous membranes
D. Blood pressure of 90/42 mm Hg
E. Urine output 500 mL past 8 hours

Correct Answer: A,C,D

Rationale: A serum osmolality of 364 mOsm/kg, very dry mucous membranes, and a BP of 90/42 indicate HHNS due to elevated osmolality, dehydration, and hypotension from osmotic diuresis.

The client is being admitted to the outpatient department prior to an endoscopic retrograde cholangiopancreatogram (ERCP) to rule out cancer of the pancreas. Which preprocedure instruction should the nurse teach?

A. Prepare to be admitted to the hospital after the procedure for observation.
B. If something happens during the procedure, then emergency surgery will be done.
C. Do not eat or drink anything after midnight the night before the test.
D. If done correctly, this procedure will correct the blockage of the stomach.

Correct Answer: C

Rationale: NPO after midnight prevents aspiration during ERCP sedation. Hospital admission, emergency surgery, and blockage correction are incorrect.

The client diagnosed with hyperthyroidism is complaining of being hot and cannot sit still. Which should the nurse do based on the assessment?

A. Continue to monitor the client.
B. Have the UAP take the client's vital signs.
C. Request an order for a sedative.
D. Insist the client lie down and rest.

Correct Answer: B

Rationale: Heat intolerance and restlessness are hyperthyroidism symptoms; vital signs assess for exacerbation (e.g., thyroid storm). Monitoring, sedatives, or rest are less appropriate.

The nurse is interviewing four clients. Which client is at the greatest risk for developing type 2 DM?

A. 56-year-old Hispanic female
B. 40-year-old Asian American female
C. 25-year-old obese Caucasian male
D. 38-year-old Native American male

Correct Answer: D

Rationale: Research has shown that the highest incidence of DM is among Native Americans.

The nurse is assessing a client with complaints of vague upper abdominal pain worse at night but relieved by sitting up and leaning forward. Which assessment question should the nurse ask next?

A. Have you noticed a yellow haze when you look at things?
B. Does the pain get worse when you eat a meal or snack?
C. Have you had your amylase and lipase checked recently?
D. How much weight have you gained since you saw an HCP?

Correct Answer: A

Rationale: The pain description suggests pancreatic cancer; jaundice (yellow haze) is a common symptom due to bile duct obstruction, guiding further assessment. Eating effects, labs, and weight gain are less specific.