Nokea
The nurse is providing teaching to a client about self-management of type 2 diabetes mellitus. Which information provided by the client indicates understanding?
- A. Get an influenza vaccine every year as soon as available.
- B. Using salt, herbs, and spices will Improve the flavor of foods.
- C. Restrict alcoholic beverages to no more than 1-2 per week.
- D. Eat a protein snack 30 minutes before any exercise workout.
Correct Answer: B
Rationale: Using herbs and spices reduces reliance on sugars and fats, supporting glycemic control in diabetes.
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The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
- A. Verify prescribed laboratory tests include prothrombin time and platelet count.
- B. Administer aspirin to prevent further clot formation and platelet clumping.
- C. Maintain elevated positioning of the dependent joints on affected side.
- D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
Correct Answer: D
Rationale: IV catheters and fibrinolytic criteria review are critical for potential thrombolytic therapy in suspected ischemic stroke.
A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?
- A. Educate client on signs and symptoms of narcotic dependency.
- B. Administer opioid and non-opioid medication simultaneously.
- C. Give maximum dosage when score reaches 10.
- D. Alternate IV and IM analgesic medications.
Correct Answer: B
Rationale: Combining opioid and non-opioid medications provides synergistic pain relief, optimizing control while minimizing opioid side effects.
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Administer pain medication at designated Intervals around the clock.
- B. Assess the pulses proximal to the fracture site.
- C. Remove traction every shift and provide skin care.
- D. Assess the pin sites for signs of infection.
Correct Answer: D
Rationale: Assessing pin sites for infection is critical in skeletal traction to prevent complications like osteomyelitis, which could delay healing.
After falling down the basement steps, a client is brought to the emergency department. X-ray results confirm that the client's right leg is fractured. Following application of a leg cast, which assessment finding warrants immediate intervention by the nurse?
- A. Increased temperature to lower extremity.
- B. Circumferential edema of right foot.
- C. Right foot pale with sluggish capillary refill.
- D. Reports throbbing right leg pain.
Correct Answer: C
Rationale: Pale foot with sluggish capillary refill indicates compromised circulation, risking tissue ischemia requiring urgent intervention.
While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?
- A. Hematocrit.
- B. Platelet count.
- C. White blood cell (WBC) count.
- D. Blood pH level.
Correct Answer: C
Rationale: WBC count indicates infection, as purulent drainage suggests bacterial colonization requiring prompt intervention.