Nokea
The nurse is developing a plan of care for an older client diagnosed with type 1 diabetes mellitus who is also experiencing acute gastroenteritis. To maintain food and fluid intake in order to prevent dehydration, which action should the nurse plan to include?
- A. Offering only water until the client is able to tolerate solid foods
- B. Withholding all fluids until vomiting has ceased entirely for at least 4 hours
- C. Encouraging the client to take 8 to 12 ounces of fluid every hour while awake
- D. Maintaining a clear liquid diet for at least 5 days before advancing to solid foods
Correct Answer: C
Rationale: Dehydration needs to be prevented in the client with type 1 diabetes mellitus because of the risk of diabetic ketoacidosis (DKA). Small amounts of fluid may be tolerated, even when vomiting is present. The client should be offered liquids containing both glucose and electrolytes. The diet should be advanced as tolerated and include a minimum of 100 to 150 g of carbohydrates daily.
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The nurse is caring for a client who has experienced a thoracic spinal cord injury. In the event that spinal shock occurs, which intravenous (IV) fluid should the nurse anticipate being prescribed?
- A. Dextran
- B. 0.9% normal saline
- C. 5% dextrose in water
- D. 5% dextrose in 0.9% normal saline
Correct Answer: B
Rationale: Normal saline 0.9% is an isotonic solution that primarily remains in the intravascular space, increasing intravascular volume. This IV fluid would increase the client's blood pressure. Dextran is rarely used in spinal shock because isotonic fluid administration is usually sufficient. Additionally, Dextran has potential adverse effects. Dextrose 5% in water is a hypotonic solution that pulls fluid out of the intravascular space and is not indicated for shock. Dextrose 5% in normal saline 0.9% is hypertonic and may be indicated for shock resulting from hemorrhage or burns.
The nurse provides a class to new mothers on newborn care. When teaching cord care, the nurse should instruct mothers to take which action?
- A. If antibiotic ointment has been applied to the cord, it is not necessary to do anything else to it.
- B. All that is necessary is to wash the cord with antibacterial soap and allow it to air-dry once a day.
- C. Apply alcohol thoroughly to the cord, being careful not to move the cord because it will cause pain to the newborn infant.
- D. Apply the prescribed cleansing agent to the cord, ensuring that all areas around the cord are cleaned two to three times a day.
Correct Answer: D
Rationale: The cord and base should be cleansed with alcohol (or another substance as prescribed) thoroughly, two to three times per day. The steps are (1) lift the cord; (2) wipe around the cord, starting at the top; (3) clean the base of the cord; and (4) fold the diaper below the umbilical cord to allow the cord to air-dry and prevent contamination from urine. Antibiotic ointment is not normally prescribed. Continuation of cord care is necessary until the cord falls off within 7 to 14 days. Water and soap are not necessary; in fact, the cord should be kept from getting wet. The infant does not feel pain in this area.
A client admitted to the hospital has been prescribed pyridostigmine. When assessing the client for side effects of the medication, the nurse should ask the client about the presence of which occurrence?
- A. Mouth ulcers
- B. Muscle cramps
- C. Feelings of depression
- D. Unexplained weight gain
Correct Answer: B
Rationale: Pyridostigmine is an acetylcholinesterase inhibitor used to treat myasthenia gravis, a neuromuscular disorder. Muscle cramps and small muscle contractions are side effects and occur as a result of overstimulation of neuromuscular receptors. Mouth ulcers, depression, and weight gain are not associated with this medication.
Which nursing assessment question should be asked to help determine the client's risk for developing malignant hyperthermia in the perioperative period?
- A. Have you ever had heat exhaustion or heat stroke?
- B. What is the normal range for your body temperature?
- C. Do you or any of your family members have frequent infections?
- D. Do you or any of your family members have problems with general anesthesia?
Correct Answer: D
Rationale: Malignant hyperthermia is a genetic disorder in which a combination of anesthetic agents (the muscle relaxant succinylcholine and inhalation agents such as halothanes) triggers uncontrolled skeletal muscle contractions that can quickly lead to a potentially fatal hyperthermia. Questioning the client about the family history of general anesthesia problems may reveal this as a risk for the client. Options 1, 2, and 3 are unrelated to this surgical complication.
The emergency department nurse is assessing a client who abruptly discontinued benzodiazepine therapy and is experiencing withdrawal. Which manifestations of withdrawal should the nurse expect to note? Select all that apply.
- A. Tremors
- B. Sweating
- C. Lethargy
- D. Agitation
- E. Nervousness
- F. Muscle weakness
Correct Answer: A,B,D,E
Rationale: Benzodiazepines should not be abruptly discontinued because withdrawal symptoms are likely to occur. Withdrawal symptoms include tremor, sweating, agitation, nervousness, insomnia, anorexia, and muscular cramps. Withdrawal symptoms from long-term, high-dose benzodiazepine therapy include paranoia, delirium, panic, hypertension, and status epilepticus. Lethargy is not associated with benzodiazepine withdrawal.