Nokea
The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include:
- A. Kussmaul's respirations
- B. Excessive hunger
- C. Dry, flaky skin
- D. High blood pressure
Correct Answer: A
Rationale: Kussmaul's respirations (rapid, deep breathing) are a hallmark of diabetic ketoacidosis as the body compensates for acidosis. Excessive hunger is more typical of hypoglycemia, and dry skin or hypertension are less specific.
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The nurse obtains a finger-stick glucose of 400 mg/dL (22.85 mmol/L) for a client who receives total parenteral nutrition (TPN). Which follow-up intervention should the nurse implement?
- A. Discontinue the current TPN infusion.
- B. Decrease the infusion rate of the TPN.
- C. Replace TPN with 5% dextrose solution.
- D. Confer with provider for glucose control.
Correct Answer: D
Rationale: A glucose level of 400 mg/dL indicates significant hyperglycemia, which is a potential complication of TPN due to its high dextrose content. The nurse should confer with the primary health care provider to obtain orders for glucose control, such as insulin administration, to manage the hyperglycemia safely. Discontinuing or altering the TPN infusion without provider orders is inappropriate, as TPN is a critical nutrition source, and abrupt changes could cause metabolic imbalances. Replacing TPN with 5% dextrose would not address the hyperglycemia and could exacerbate it.
You are caring for a postoperative client who is complaining of abdominal distention and flatus. Which intervention would you most likely do for this client?
- A. A cleansing enema
- B. A retention enema
- C. A return-flow enema
- D. A laxative
Correct Answer: C
Rationale: A return-flow enema is used to relieve gas and distention by introducing and withdrawing fluid to stimulate gas expulsion.
A client with a diagnosis of multiple sclerosis is prescribed baclofen (Lioresal). The nurse should monitor the client for which of the following side effects?
- A. Hypertension.
- B. Drowsiness.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: B
Rationale: Baclofen, a muscle relaxant, commonly causes drowsiness, which the nurse should monitor in clients with multiple sclerosis.
The nurse is assessing a client with suspected appendicitis. Which finding supports this diagnosis?
- A. Pain relief with knee flexion.
- B. Rebound tenderness in the right lower quadrant.
- C. Increased bowel sounds.
- D. Absence of fever.
Correct Answer: B
Rationale: Rebound tenderness in the right lower quadrant is a classic sign of appendicitis due to peritoneal irritation.
Assessment of a primigravid client in active labor reveals a cervix dilated to 5 cm and completely effaced, with the fetus at -1 station. The client has indicated that she wants a 'natural childbirth' with no analgesia or anesthesia. The client's husband has been present since their arrival at the birthing unit. The physician enters the room and tells the client that it is time for an epidural anesthetic. Which of the following would be the nurse's best action at this time?
- A. Ask the client if she desires an epidural anesthetic.
- B. Tell the physician that the client desires a natural childbirth with no analgesia or anesthesia.
- C. Tell the client that her labor will be more comfortable with an anesthetic.
- D. Ask the client to discuss this with her husband and then make a decision.
Correct Answer: B
Rationale: Advocating for the client's stated preference for natural childbirth ensures autonomy and respects her birth plan.