Nokea
The nurse is preparing a 50 ml dose of 50% dextrose IV for a client with insulin shock. What is the most immediate intervention by the nurse?
- A. Dilute the dextrose in one liter of 0.9% Normal Saline solution.
- B. Mix the dextrose in a 50 ml piggyback for a total volume of 100 ml.
- C. Push the undiluted dextrose slowly through the current IV infusion.
- D. Ask the pharmacist to add the dextrose to a TPN solution.
Correct Answer: C
Rationale: The correct immediate intervention by the nurse in this situation is to push the undiluted 50% dextrose slowly through the current IV infusion. This is because in cases of insulin shock, where the client has dangerously low blood sugar levels, administering 50% dextrose directly into the bloodstream helps rapidly increase blood glucose levels. Choice A is incorrect because diluting the dextrose in one liter of normal saline would delay the administration of glucose, which is needed urgently. Choice B is incorrect as mixing the dextrose in a piggyback solution would also delay the administration of the concentrated dextrose. Choice D is incorrect because adding dextrose to a TPN solution is not the immediate intervention needed to address the low blood sugar levels in a client experiencing insulin shock.
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During orientation, a newly hired nurse demonstrates suctioning of a tracheostomy in a skills class. After the demonstration, the supervising nurse expresses concern that the demonstrated procedure increased the client's risk for which problem?
- A. Infection
- B. Hypoxia
- C. Bleeding
- D. Bronchospasm
Correct Answer: A
Rationale: The correct answer is A: Infection. Improper suctioning techniques can introduce pathogens, increasing the risk of infection. Choice B, Hypoxia, is incorrect as it is more related to inadequate oxygen supply. Choice C, Bleeding, is not typically associated with suctioning a tracheostomy unless done too aggressively. Choice D, Bronchospasm, is not directly linked to suctioning but may occur due to other triggers in patients with sensitive airways.
A client is admitted for type 2 diabetes mellitus (DM) and chronic kidney disease (CKD). Which breakfast selection by the client indicates effective learning?
- A. Scrambled eggs, bacon, one slice of whole wheat toast with butter and jam.
- B. Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces of coffee.
- C. Banana pancake with maple syrup, sausage links, half grapefruit, and low-fat milk.
- D. Orange juice, yogurt with berries, cold cereal with milk, bran muffin with margarine.
Correct Answer: B
Rationale: The correct answer is B. Oatmeal with butter, artificial sweetener, and strawberries is a suitable choice for a client with type 2 diabetes mellitus and chronic kidney disease as it provides a balanced meal that helps manage blood sugar levels and kidney function. Choice A contains high saturated fats and added sugars from bacon, butter, and jam, which are not ideal for this client. Choice C includes high sugar content from maple syrup and pancake, which can negatively impact blood sugar levels. Choice D contains high sugar content from orange juice and cold cereal, which can lead to blood sugar spikes, not suitable for a client with diabetes and CKD.
The nurse is caring for a client who is postoperative following a thyroidectomy. Which assessment finding is most concerning?
- A. Slight difficulty swallowing
- B. Hoarse voice
- C. Positive Chvostek's sign
- D. Pain at the incision site
Correct Answer: C
Rationale: A positive Chvostek's sign is the most concerning assessment finding as it suggests hypocalcemia, which is a potential complication following thyroidectomy. Hypocalcemia can lead to serious complications such as tetany and laryngospasm. Immediate intervention is required to prevent further complications. Choices A, B, and D are common post-thyroidectomy findings and are expected during the immediate postoperative period. Slight difficulty swallowing may be due to postoperative swelling, a hoarse voice may be temporary due to intubation trauma, and pain at the incision site is normal after surgery.
The nurse is caring for a client with end-stage renal disease (ESRD) who is scheduled for hemodialysis. Which assessment finding is most concerning?
- A. Blood pressure of 110/70 mmHg
- B. Heart rate of 110 beats per minute
- C. Fever of 100.4°F
- D. Respiratory rate of 24 breaths per minute
Correct Answer: C
Rationale: A fever of 100.4°F is the most concerning assessment finding in a client with ESRD scheduled for hemodialysis. This elevation in temperature may indicate an underlying infection, which can lead to serious complications in individuals with compromised renal function. Prompt intervention is necessary to prevent the spread of infection and deterioration of the client's condition. The other vital signs mentioned, such as blood pressure, heart rate, and respiratory rate, while important to monitor, are within acceptable ranges and do not pose an immediate threat like a fever indicative of infection.
A client with a history of atrial fibrillation is admitted with a new onset of confusion. Which intervention should the nurse implement first?
- A. Obtain a blood glucose level.
- B. Administer an anticoagulant as prescribed.
- C. Perform a neurological assessment.
- D. Administer aspirin as prescribed.
Correct Answer: C
Rationale: Performing a neurological assessment is the priority in this situation as it helps in evaluating the cause of the new onset of confusion in a client with atrial fibrillation. This assessment will provide crucial information about the client's neurological status, which can guide further interventions. Obtaining a blood glucose level (Choice A) is important but should not be the first step when dealing with a new onset of confusion. Administering an anticoagulant (Choice B) or aspirin (Choice D) may be necessary depending on the underlying cause, but assessing the neurological status comes first to determine the appropriate course of action.