Nokea
The nurse is teaching a client with a history of type 2 diabetes about foot care. The nurse should tell the client to:
- A. Inspect feet daily
- B. Soak feet in hot water
- C. Wear tight shoes
- D. Cut toenails with scissors
Correct Answer: A
Rationale: Daily foot inspection helps detect early signs of injury or infection in type 2 diabetes, preventing complications like ulcers.
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During the change of shift report, a nurse writes in her notes that she suspects illegal drug use by a client assigned to her care. During the shift, the notes are found by the client's daughter. The nurse could be sued for:
- A. Libel
- B. Slander
- C. Malpractice
- D. Negligence
Correct Answer: A
Rationale: Libel involves written defamatory statements, such as unverified suspicions of drug use in notes accessible to others, potentially harming the client's reputation.
The nurse is assessing a client with suspected anaphylactic shock. Which intervention is the priority?
- A. Administer epinephrine
- B. Start an IV fluid bolus
- C. Place the client in Trendelenburg position
- D. Administer oxygen via nasal cannula
Correct Answer: A
Rationale: Epinephrine is the priority in anaphylactic shock to reverse bronchoconstriction and hypotension. IV fluids and oxygen are secondary, and Trendelenburg is not recommended.
When a client is receiving vasoactive therapy IV, such as dopamine (Intropin), and extravasation occurs, the nurse should be prepared to administer which of the following medications directly into the site?
- A. Phentolamine (Regitine)
- B. Epinephrine
- C. Phenylephrine (Neo-Synephrine)
- D. Sodium bicarbonate
Correct Answer: A
Rationale: Phentolamine is given to counteract the-adrenergic effects that cause ischemia and necrosis of local tissue. Epinephrine is an endogenous catecholamine that produces vasoconstriction and increases heart rate and contractility. Phenylephrine causes constriction of arterioles of skin, mucous membranes, and viscera, which in turn can cause ischemia and necrosis. Sodium bicarbonate is an alkalinizing agent that is incompatible with dopamine.
A client is being discharged from the hospital tomorrow following a colon resection with a left colostomy. The nurse knows that the client understands the discharge teaching about care of her colostomy when she says:
- A. I know that I am not supposed to irrigate my colostomy.'
- B. My stool will be soft like paste.'
- C. My stoma should be red and slightly raised.'
- D. The skin around my stoma may become irritated from the enzymes in my stool.'
Correct Answer: C
Rationale: The healthy stoma should be red and slightly raised. If it begins to turn dark or blue, the client should see the physician immediately.
The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:
- A. Mix the insulin with Dextrose 5% in water.
- B. Flush the IV tubing with the insulin solution and discard the first 50 mL.
- C. Give the insulin without diluting.
- D. Add the insulin to a solution of normal saline.
Correct Answer: D
Rationale: Regular insulin for IV infusion should be diluted in normal saline to ensure compatibility and prevent adsorption to IV tubing. Dextrose is inappropriate during DKA, and flushing with insulin wastes medication.