Nokea
The nurse is providing discharge teaching to a client with newly diagnosed type 2 diabetes mellitus. Which instruction is most important to prevent complications?
- A. Monitor blood glucose levels regularly
- B. Maintain a low-fat diet
- C. Exercise regularly
- D. Take medication as prescribed
Correct Answer: A
Rationale: Regular monitoring of blood glucose levels is crucial in managing diabetes and preventing complications. This allows the client and healthcare team to make timely adjustments to the treatment plan. While maintaining a low-fat diet, exercising regularly, and taking medication as prescribed are all important aspects of diabetes management, monitoring blood glucose levels takes precedence as it provides real-time information about the client's condition and helps prevent acute complications.
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The client with diabetes is being taught about the importance of foot care. Which statement by the client indicates a need for further teaching?
- A. ''I will inspect my feet daily for any cuts or blisters.''
- B. ''I will soak my feet in warm water every day.''
- C. ''I will wear shoes that fit properly to avoid injury.''
- D. ''I will avoid walking barefoot to protect my feet.''
Correct Answer: B
Rationale: Choice B is the correct answer because soaking feet daily can lead to skin breakdown, making it inappropriate for clients with diabetes. Inspecting feet daily for cuts or blisters (Choice A), wearing properly fitting shoes (Choice C), and avoiding walking barefoot (Choice D) are all appropriate measures to maintain foot health for clients with diabetes.
How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?
- A. Abnormal skin color changes in a client with dark skin cannot be determined
- B. Blanching the soles of the feet in a client with dark skin reveals cyanosis
- C. The lips and mucus membranes of a client with dark skin are dusky in color
- D. Cyanosis in a client with dark skin is seen in the sclera
Correct Answer: C
Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.
The nurse is caring for a client with acute pancreatitis. Which intervention should be included in the plan of care?
- A. Provide a high-protein diet
- B. Encourage oral fluids
- C. Administer intravenous fluids as prescribed
- D. Monitor for signs of hyperglycemia
Correct Answer: C
Rationale: The correct intervention to include in the plan of care for a client with acute pancreatitis is to administer intravenous fluids as prescribed. Intravenous fluids are crucial to maintain hydration and electrolyte balance in clients with acute pancreatitis. Providing a high-protein diet (Choice A) is not recommended initially for clients with acute pancreatitis, as they may need to be kept NPO (nothing by mouth) to rest the pancreas. Encouraging oral fluids (Choice B) may not be appropriate if the client is experiencing severe symptoms and requires intravenous fluids. Monitoring for signs of hyperglycemia (Choice D) is important but not the immediate intervention needed to address the fluid and electrolyte imbalances associated with acute pancreatitis.
While caring for a client who is being mechanically ventilated, the nurse responds to a high-pressure alarm on the ventilator. Which assessment finding warrants immediate intervention by the nurse?
- A. Endotracheal cuff pressure greater than 25 cm H2O.
- B. Decreased lung compliance during ventilation.
- C. Bilateral crackles with increased secretions.
- D. Restless client who is biting the endotracheal tube.
Correct Answer: D
Rationale: A restless client biting the endotracheal tube can increase airway resistance, triggering the high-pressure alarm and indicating a need for immediate intervention. This behavior can lead to complications such as dislodgement of the tube or airway obstruction. Endotracheal cuff pressure greater than 25 cm H2O, decreased lung compliance, and bilateral crackles with increased secretions are important assessments but do not directly address the urgent need to intervene when a high-pressure alarm is triggered.
A client with diabetes exhibits a blood sugar of 350 mg/dL. What is the nurse's best action?
- A. Administer insulin as prescribed
- B. Provide a carbohydrate-controlled snack
- C. Encourage physical activity
- D. Recheck the blood sugar
Correct Answer: A
Rationale: In a client with diabetes presenting with a blood sugar level of 350 mg/dL, the best action for the nurse is to administer insulin as prescribed. High blood sugar levels can lead to complications like diabetic ketoacidosis, making prompt insulin administration crucial to lower the blood glucose level. Providing a carbohydrate-controlled snack would be inappropriate as it may further elevate blood sugar levels. Encouraging physical activity is not advisable when the blood sugar is significantly high, as exercise can raise blood sugar levels. Rechecking the blood sugar is necessary after administering insulin to monitor the response to treatment.