Nokea
The nurse is teaching a client with a new diagnosis of type 2 diabetes about foot care. Which of the following instructions should be included? Select all that apply.
- A. Inspect feet daily for cuts or sores.
- B. Wear well-fitting shoes.
- C. Soak feet in hot water daily.
- D. Apply lotion between the toes.
- E. Trim toenails straight across.
Correct Answer: A, B, E
Rationale: Daily inspection, well-fitting shoes, and straight toenail trimming prevent complications. Hot water and lotion between toes increase infection risk.
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A client with a history of asthma reports increased wheezing. Which medication should the nurse prepare to administer?
- A. Prednisone.
- B. Albuterol.
- C. Montelukast.
- D. Cromolyn sodium.
Correct Answer: B
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute asthma exacerbations to relieve bronchospasm.
A 24-year-old nulligravid client with a history of irregular menstrual cycles visits the clinic because she suspects that she is 'about 6 weeks pregnant.' An ultrasound is scheduled in 2 weeks. The nurse should instruct the client that this test will be done to:
- A. Assess gestational age.
- B. Determine a multifetal pregnancy.
- C. Identify the gender of the fetus.
- D. Assess of maternal pelvic adequacy.
Correct Answer: A
Rationale: An early ultrasound at around 8 weeks is primarily used to confirm gestational age and viability.
A client with a history of duodenal ulcer is taking calcium carbonate chewable tablets. The nurse monitors the client for relief of which symptom?
- A. Flatus
- B. Heartburn
- C. Rectal pain
- D. Muscle twitching
Correct Answer: B
Rationale: Calcium carbonate is used as an antacid for the relief of heartburn and indigestion. It can also be used as a calcium supplement or to bind phosphorus in the gastrointestinal tract in clients with renal failure. The remaining options are unrelated to this medication.
Your 87 year old client has a history of heart disease and fibromyalgia. This client has an internal pacemaker and is also a diabetic client. During your annual visit with this client, the client tells you that they would like to begin some alternative and homeopathic health care practices. What should you include in your teaching plan for this client?
- A. Information about the lack of scientific evidence regarding the effectiveness of all herbs.
- B. Data to support the fact that magnets can be effective in terms of fibromyalgia pain, and as such, may be a good choice for this client.
- C. Research that suggests that prayer is an effective alternative method to relieve pain and stress that can be helpful to this client.
- D. Information that contraindicates the use of biofeedback because this alternative, complementary health practice can interfere with the client's pacemaker functioning.
Correct Answer: C
Rationale: Prayer is a safe and evidence-supported complementary practice that can help reduce stress and pain, suitable for this client. There is insufficient evidence for magnets in fibromyalgia treatment, and biofeedback is not contraindicated for pacemakers. Not all herbs lack scientific evidence, so option A is overly broad.
A client with a history of heart failure is prescribed spironolactone (Aldactone). Which electrolyte imbalance should the nurse monitor for?
- A. Hypokalemia
- B. Hyperkalemia
- C. Hyponatremia
- D. Hypercalcemia
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia, requiring monitoring to prevent arrhythmias.