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The nurse is reviewing the serum laboratory report for the hospitalized client who has adrenocortical insufficiency. The nurse should immediately notify the HCP about which value?
- A. WBC 11,000/mm3
- B. Glucose 138 mg/dL
- C. Sodium 148 mEq/L
- D. Potassium 6.2 mEq/L
Correct Answer: D
Rationale: The serum potassium of 6.2 mEq/L indicates hyperkalemia, which can cause dysrhythmias and requires immediate notification.
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The home health nurse is completing the first home visit for the elderly Hispanic client newly diagnosed with type 2 DM. The client has been instructed on self-administering NPH and regular insulin in the morning and at suppertime. What information should the nurse reinforce when teaching the client? Select all that apply.
- A. Inspect the feet and between the toes daily.
- B. Use magnifying devices to read small print.
- C. Perform a hemoglobin A1c test once a week.
- D. Eat a 15-gram carbohydrate snack at bedtime.
- E. Inject 1 unit of NPH insulin after eating a snack
Correct Answer: A,B,D
Rationale: Daily foot inspection prevents complications, magnifying devices prevent dosing errors, and a bedtime snack covers insulin peaks to prevent hypoglycemia.
The nurse is caring for the client newly diagnosed with hypothyroidism. Which problem should the nurse include in the plan of care?
- A. Diarrhea due to gastrointestinal (GI) hypermotility
- B. Imbalanced nutrition due to insufficient calorie intake
- C. Activity intolerance due to increased metabolic rate
- D. Anxiety due to forgetfulness and slowed speech
Correct Answer: D
Rationale: Forgetfulness and slowed speech that occur with hypothyroidism can cause the client to be anxious.
The client diagnosed with acute pancreatitis has a ruptured pseudocyst. Which procedure should the nurse anticipate the HCP prescribing?
- A. Paracentesis.
- B. Chest tube insertion.
- C. Lumbar puncture.
- D. Biopsy of the pancreas.
Correct Answer: A
Rationale: A ruptured pancreatic pseudocyst can cause peritoneal irritation or fluid accumulation, potentially requiring drainage. Paracentesis removes abdominal fluid, which may be performed in severe cases, though surgical drainage or endoscopic intervention is more specific. Chest tube insertion is for pleural issues, lumbar puncture is for cerebrospinal fluid, and pancreatic biopsy is diagnostic, not therapeutic for a ruptured pseudocyst.
The nurse is reviewing information for the client with type 1 DM. The nurse concludes that the client may be experiencing the Somogyi phenomenon, as evidenced by which finding?
- A. 02:00 blood glucose between 80-110 mg/dL and morning levels between 80-100 mg/dL
- B. 02:00 blood glucose between 50-60 mg/dL and morning levels between 48-62 mg/dL
- C. 02:00 blood glucose between 130-140 mg/dL and morning levels between 180-200 mg/dL
- D. 02:00 blood glucose between 45-62 mg/dL and morning levels between 200-305 mg/dL
Correct Answer: D
Rationale: The nurse should conclude that the low blood glucose in the middle of the night (45-62 mg/dL) and a rebound morning hyperglycemia (200-305 mg/dL) are signs of Somogyi phenomenon, also known as Somogyi effect.
The nurse is completing discharge teaching to the client diagnosed with acute pancreatitis. Which instruction should the nurse discuss with the client?
- A. Instruct the client to decrease alcohol intake.
- B. Explain the need to avoid all stress.
- C. Discuss the importance of stopping smoking.
- D. Teach the correct way to take pancreatic enzymes.
Correct Answer: A
Rationale: Decreasing alcohol intake is critical, as alcohol is a major cause of pancreatitis. Stress avoidance is unrealistic, smoking is secondary, and enzymes are for chronic cases.