Nokea
The nurse is discussing discharge plans with a client who had a transsphenoidal hypophysectomy. Which statement made by the client indicates a need for more teaching?
- A. I won't brush my teeth until the doctor removes the stitches.'
- B. I will wear loafers instead of tie shoes.'
- C. Where can I get a Medic-Alert bracelet?'
- D. I will take all these new medicines until I feel better.'
Correct Answer: D
Rationale: Stopping medications when feeling better indicates a lack of understanding, as lifelong hormone replacement is often required post-hypophysectomy.
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How does the nurse expect the urine that is collected for a routine urinalysis to appear?
- A. Tea-colored
- B. Pale yellow
- C. Goldless
- D. Light pink
Correct Answer: B
Rationale: In diabetes insipidus, the urine is typically dilute and pale yellow due to the large volume of water excreted.
The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem 'high risk for hyperglycemia related to noncompliance with the medication regimen.' Which statement is an appropriate short-term goal for the client?
- A. The client will have a blood glucose level between 90 and 140 mg/dL.
- B. The client will demonstrate appropriate insulin injection technique.
- C. The nurse will monitor the client's blood glucose levels four (4) times a day.
- D. The client will maintain normal kidney function with 30-mL/hr urine output.
Correct Answer: B
Rationale: Demonstrating correct insulin injection technique addresses noncompliance, a short-term, client-centered goal. Glucose levels and kidney function are outcomes, and nurse monitoring is not client-focused.
The health-care provider has ordered 40 g/24 hr of intranasal vasopressin for a client diagnosed with diabetes insipidus. Each metered spray delivers 10 g. The client takes the medication every 12 hours. How many sprays are delivered at each dosing time?
Correct Answer: 2 sprays
Rationale: Total dose: 40 g/24 hr, split every 12 hr = 20 g/dose. Each spray = 10 g, so 20 g ÷ 10 g/spray = 2 sprays per dose.
The nurse should assess for hypocalcemia based on which client statements after a subtotal thyroidectomy?
- A. I feel tingling in my hands and feet.
- B. I have a headache.
- C. I feel sleepy.
- D. I have a sore throat.
Correct Answer: A
Rationale: Tingling in the hands and feet indicates hypocalcemia, a potential complication due to parathyroid gland damage during thyroidectomy.
The nurse reviews the HCP's orders for the newly admitted client diagnosed with DKA. Which order should the nurse question?
- A. Administer D5W intravenously (IV) at 125 mL per hour
- B. Administer KCL 10 mEq in 100 mL NaCl IV now
- C. Give sodium bicarbonate IV per pharmacy dosing if arterial pH is less than 7.0
- D. Start regular insulin infusion per protocol; titrate based on hourly glucose level
Correct Answer: A
Rationale: In DKA, the blood glucose level is above 300 mg/dL. Additional glucose will increase the glucose level further. Initially 0.45% or 0.9% sodium chloride (NaCl) is administered for fluid resuscitation.