Nokea
The nurse is planning a staff development conference about diabetic ketoacidosis (DKA). Which of the following information should the nurse include?
- A. The goal is to lower blood glucose by 50 to 75 mg/dL/hr (2.775 to 4.165 mmol/L/hr).
- B. Dextrose 5% in water (D5W) should be available to treat symptoms of hypoglycemia.
- C. Hypovolemia caused by DKA may be treated with 3% saline.
- D. The urine output would increase once regular insulin is initiated.
Correct Answer: A, B, D
Rationale: The goal is to lower glucose gradually, D5W treats hypoglycemia, and insulin increases urine output by correcting osmotic diuresis. 3% saline is not used for hypovolemia in DKA.
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When assessing a postpartum client, a nurse notes that the client has soaked three perineal pads in the three hours since delivery. The nurse also notes a soft fundus. The initial action for the nurse would be which of the following?
- A. Insert vaginal packing
- B. Massage the client's fundus
- C. Apply an ice pack over the client's perineal area
- D. Administer packed red blood cells
Correct Answer: B
Rationale: A soft fundus and heavy bleeding suggest uterine atony, a common cause of postpartum hemorrhage. Fundal massage is the initial action to stimulate uterine contraction.
The nurse in the emergency department (ED) is caring for a 10-year-old client.
Item 5 of 5
Nurses' Notes
1322: 10-year-old client and his parents report an 8-day history of a brownish-raised lesion over the back of his left leg. The parents report that the size of the rash has increased. The parents report returning from a one-week camping trip three weeks ago. The parents deny efficacy with over-the-counter antihistamine creams. The client's parents deny that the child has had a fever but has felt 'warm' occasionally and endorsed an intermittent headache. They report an area of firmness in the child's groin. On assessment, there was an erythematous, raised, nonpainful, oval patch on the back of his left leg. This was an enlargement of an inguinal lymph node. The child is alert and fully oriented and denies any pain. Peripheral pulses palpable 2+. No cyanosis or edema in the extremities. Lung sounds clear bilaterally. The parents report that the child did not receive the seasonal influenza vaccine. He currently takes a multivitamin for iron deficiency anemia and was hospitalized one year ago for an appendectomy. The parents state that the child’s sibling had influenza one month ago. Vital signs: T 98.8°F (37.1°C); HR 78 beats/min; RR 16 breaths/min; BP 110/76 mm Hg. SpO2 97% on room air.
Progress Notes
1401: The client was evaluated. The rash is localized, raised, and appears like a bullseye. The client has inguinal lymphadenopathy. The client's recent camping trip supports the probability of a vector-borne illness—specifically, Lyme disease.
Orders
• laboratory tests: IgM and IgG antibodies
• doxycycline 100 mg capsule p.o. twice daily for fourteen days
• discharge client home
• follow-up with a primary care physician in two weeks
The nurse reviews and executes the physician's orders. Which of the following actions should the nurse take when performing venipuncture on a 10-year-old client?
- A. Identify the child by only checking their identification armband.
- B. Apply a cold compress to the area to promote vasodilation.
- C. Demonstrate the procedure using a stuffed animal.
- D. Allow the child to decide which arm they would like for the venipuncture.
- E. Ask the child if they want to help set up some equipment.
- F. Offer the child a sedative to help them relax before the procedure.
Correct Answer: C, D, E
Rationale: Demonstrating on a stuffed animal, allowing arm choice, and involving the child in setup reduce anxiety and promote cooperation. Cold compresses constrict vessels, and sedatives are not routinely offered.
The nurse cares for a client immediately following a shoulder reduction procedure with moderate sedation. The nurse assesses the client as restless and irritable. The nurse should take which priority action?
- A. Assess the client for pain
- B. Assess the client's oxygen saturation
- C. Assess the client with the Glasgow Coma Scale (GCS)
- D. Assess the client's lung sounds
Correct Answer: B
Rationale: Restlessness and irritability post-sedation may indicate hypoxia. Assessing oxygen saturation is the priority to ensure airway and breathing stability.
The nurse assists a client with cystic fibrosis in picking out items on a menu. It will indicate effective teaching if the client selects meals that are
- A. high in fat
- B. low in sodium
- C. low in calories
- D. low in protein
Correct Answer: A
Rationale: High-fat meals provide necessary calories for cystic fibrosis patients with high energy needs.
The nurse is conducting a community health course. The nurse recognizes which of the following would be an example of secondary prevention?
- A. Sexually transmitted disease (STD) partner notification
- B. Human immunodeficiency virus (HIV) PrEP pre-exposure prophylaxis
- C. Reviewing safe food-handling practices in the home
- D. Cardiac rehabilitation following a heart attack
Correct Answer: A
Rationale: STD partner notification is secondary prevention, aiming to detect and treat disease early.