Nokea
The nurse is planning to complete noon assessments for four assigned clients with type 1 DM. All of the clients received subcutaneous insulin aspart at 0800 hours. Place the clients in the order of priority for the nurse's assessment.
- A. The 60-year-old client who is nauseated and has just vomited for the second time
- B. The 45-year-old client who is dyspneic and has chest pressure and new-onset atrial fibrillation
- C. The 75-year-old client with a fingerstick blood glucose level of 300 mg/dL
- D. The 50-year-old client with a fingerstick blood glucose level of 70 mg/dL
Correct Answer: B,A,C,D
Rationale: The 45-year-old client with dyspnea, chest pressure, and atrial fibrillation is at risk for a cardiac event, requiring immediate assessment. The 60-year-old with vomiting is next due to potential hypoglycemia. The 75-year-old with hyperglycemia needs attention but is less urgent. The 50-year-old with normal glucose is last.
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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 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.
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.
Which psychosocial problem should be included in the plan of care for a female client diagnosed with Cushing's syndrome?
- A. Altered glucose metabolism.
- B. Body image disturbance.
- C. Risk for suicide.
- D. Impaired wound healing.
Correct Answer: B
Rationale: Body image disturbance addresses Cushing’s physical changes (e.g., moon face, hirsutism), a key psychosocial issue. Glucose, suicide, and healing are physiological.
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.