Nokea
The nurse receives orders for the newly admitted client with Addison's disease. Which orders should the nurse question with the HCP? Select all that apply.
- A. Potassium 20 mEq oral now
- B. Sodium-restricted diet of 1000 mg
- C. Serum cortisol level in early am.
- D. Obtain serum glucose level now
- E. 5% dextrose in NS at 100 mL/hr
Correct Answer: A,B
Rationale: Potassium administration and a sodium-restricted diet are inappropriate as Addison's disease causes hyperkalemia and hyponatremia.
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To detect complications of surgery in the immediate postoperative period, which assessment component is most important for the nurse to monitor?
- A. Blood pressure
- B. Urine output
- C. Upperness
- D. Specific gravity
Correct Answer: A
Rationale: Blood pressure monitoring detects adrenal insufficiency or bleeding post-adrenalectomy.
The nurse is discussing the importance of exercising with a client diagnosed with type 2 diabetes whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes?
- A. Eat a simple carbohydrate snack before exercising.
- B. Carry peanut butter crackers when exercising.
- C. Encourage the client to walk 20 minutes three (3) times a week.
- D. Perform warm-up and cool-down exercises.
Correct Answer: D
Rationale: Warm-up and cool-down exercises prevent injury during exercise, crucial for type 2 diabetics. Pre-exercise snacks are for insulin users, peanut butter is high-fat, and walking is good but not the focus.
The nurse observes a colleague caring for the client who had a hypophysectomy via the transsphenoidal approach 12 hours ago. Which action would require the observing nurse to intervene?
- A. Elevates the head of the client's bed to 30 degrees
- B. Gathers supplies to replace the bloody nasal packing
- C. Moisturizes the client's oral mucous membranes
- D. Places a cold washcloth over the client's swollen eyes
Correct Answer: B
Rationale: Nasal packing is left in place for 3-4 days post-hypophysectomy and should not be changed without an HCP order.
Which signs/symptoms should the nurse expect to assess in the client diagnosed with an insulinoma?
- A. Nervousness, jitteriness, and diaphoresis.
- B. Flushed skin, dry mouth, and tented skin turgor.
- C. Polyuria, polydipsia, and polyphagia.
- D. Hypertension, tachycardia, and feeling hot.
Correct Answer: A
Rationale: An insulinoma is a pancreatic tumor causing excessive insulin secretion, leading to hypoglycemia. Symptoms include nervousness, jitteriness, and diaphoresis (Whipple’s triad). Flushed skin and dehydration suggest hyperglycemia, polyuria/polydipsia/polyphagia are diabetes symptoms, and hypertension/tachycardia are more typical of pheochromocytoma.
The nurse is planning to address diabetic meal planning with the client recently diagnosed with type 1 DM. Which action should the nurse take first?
- A. Encourage use of non-nutritive sweeteners that contain no calories.
- B. Emphasize the importance of keeping regular mealtimes every day.
- C. Teach the client how to count the carbohydrates in meals and snacks.
- D. Ask the client to identify favorite foods and the client's usual mealtimes.
Correct Answer: D
Rationale: Asking about favorite foods and usual mealtimes is an assessment question used in obtaining a thorough diet history; the nurse should take this action first prior to beginning teaching.