Nokea
The nurse is teaching the client about home blood glucose monitoring. Which of the following blood glucose measurements indicates hypoglycemia?
- A. 59 mg/dL.
- B. 75 mg/dL.
- C. 108 mg/dL.
- D. 119 mg/dL.
Correct Answer: A
Rationale: A blood glucose level of 59 mg/dL is below the normal range (<70 mg/dL) and indicates hypoglycemia, requiring immediate intervention.
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After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.
The nurse has calculated a low PaO2/FIO2 (P/F) ratio <150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions?
- A. Supine.
- B. Semi-Fowler's.
- C. Lateral side.
- D. Prone.
Correct Answer: D
Rationale: Prone positioning in ARDS with a low P/F ratio (<150) improves oxygenation, ventilation distribution, and secretion drainage by recruiting dependent lung regions. Other positions are less effective.
A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
- A. The skin around the stoma is red.
- B. The urine is a deep yellow.
- C. There is no odor present.
- D. The seal around the stoma is intact.
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.
A client with terminal cancer wishes to die at home. The nurse should:
- A. Arrange for home hospice services.
- B. Encourage hospitalization for better care.
- C. Advise against it due to lack of equipment.
- D. Inform the client it's not possible.
Correct Answer: A
Rationale: Arranging home hospice services supports the client's wish to die at home, providing necessary care and support in a comfortable environment.