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 is preparing to administer a.m. medications to clients. Which medication should the nurse question before administering?
- A. Pancreatic enzymes to the client who has finished breakfast.
- B. The pain medication, morphine, to the client who has a respiratory rate of 20.
- C. The loop diuretic to the client who has a serum potassium level of 3.9 mEq/L.
- D. The beta blocker to the client who has an apical pulse of 68 bpm.
Correct Answer: A
Rationale: Pancreatic enzymes should be taken with meals, not after, to aid digestion. Morphine, diuretics, and beta blockers are appropriate based on the data.
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.
Which problem is most likely to develop if hyperthyroidism remains untreated?
- A. Pulmonary embolism
- B. Respiratory acidosis
- C. Cerebro vascular accident
- D. Heart failure
Correct Answer: D
Rationale: Untreated hyperthyroidism causes severe tachycardia, which can lead to heart failure due to increased cardiac workload.
The client taking thyroid replacement hormone is hospitalized, and a thyroid replacement hormone is not prescribed. A week after being hospitalized, the nurse assesses that the client is becoming increasingly lethargic and has a decreased blood pressure, respiratory rate, temperature, and pulse. Which actions should be taken by the nurse? Place each nursing action in the order of priority.
- A. Warm the client
- B. Administer intravenous fluids
- C. Assist in ventilatory support
- D. Administer thyroxine as prescribed
Correct Answer: C,B,A,D
Rationale: Ventilatory support addresses decreased respiratory rate, IV fluids treat hypotension, warming prevents metabolic demand increase, and thyroxine corrects hypothyroidism.
The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement?
- A. Start an IV with an 18-gauge needle and infuse NS rapidly.
- B. Have the client wait in the waiting room until a bed is available.
- C. Obtain a permit for the client to receive a blood transfusion.
- D. Collect urinalysis and blood samples for a CBC and calcium level.
Correct Answer: A
Rationale: Lethargy, confusion, and weakness suggest Addisonian crisis; rapid NS infusion corrects hypotension and dehydration. Waiting, transfusions, and labs are inappropriate first steps.