Nokea
The nurse reviews the HCP's orders for the newly admitted client diagnosed with DKA. Which order should the nurse question?
- A. Administer D5W intravenously (IV) at 125 mL per hour
- B. Administer KCL 10 mEq in 100 mL NaCl IV now
- C. Give sodium bicarbonate IV per pharmacy dosing if arterial pH is less than 7.0
- D. Start regular insulin infusion per protocol; titrate based on hourly glucose level
Correct Answer: A
Rationale: In DKA, the blood glucose level is above 300 mg/dL. Additional glucose will increase the glucose level further. Initially 0.45% or 0.9% sodium chloride (NaCl) is administered for fluid resuscitation.
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The nurse is planning to complete noon assessments for four assigned clients with type 1 DM. All of the clients received subcutaneous insulin aspart at 0800 hours. Place the clients in the order of priority for the nurse's assessment.
- A. The 60-year-old client who is nauseated and has just vomited for the second time
- B. The 45-year-old client who is dyspneic and has chest pressure and new-onset atrial fibrillation
- C. The 75-year-old client with a fingerstick blood glucose level of 300 mg/dL
- D. The 50-year-old client with a fingerstick blood glucose level of 70 mg/dL
Correct Answer: B,A,C,D
Rationale: The 45-year-old client with dyspnea, chest pressure, and atrial fibrillation is at risk for a cardiac event, requiring immediate assessment. The 60-year-old with vomiting is next due to potential hypoglycemia. The 75-year-old with hyperglycemia needs attention but is less urgent. The 50-year-old with normal glucose is last.
Based on the knowledge that clients with Cushing's syndrome heal slowly, which nursing measure is most appropriate during the client's postoperative period?
- A. Monitoring infusion of I.V. antibiotics
- B. Removing tape toward the incision site
- C. Increasing the client's dietary protein intake
- D. Covering the wound with gauze
Correct Answer: C
Rationale: Increased dietary protein supports tissue repair and healing in Cushing's syndrome.
The nurse is developing a care plan for the client diagnosed with type 1 diabetes. The nurse identifies the problem 'high risk for hyperglycemia related to noncompliance with the medication regimen.' Which statement is an appropriate short-term goal for the client?
- A. The client will have a blood glucose level between 90 and 140 mg/dL.
- B. The client will demonstrate appropriate insulin injection technique.
- C. The nurse will monitor the client's blood glucose levels four (4) times a day.
- D. The client will maintain normal kidney function with 30-mL/hr urine output.
Correct Answer: B
Rationale: Demonstrating correct insulin injection technique addresses noncompliance, a short-term, client-centered goal. Glucose levels and kidney function are outcomes, and nurse monitoring is not client-focused.
Which client statement indicates a correct understanding of corticosteroid therapy for Addison's disease?
- A. I can stop the medication if I feel better.
- B. I need to take this medication daily.
- C. I should take it only during stress.
- D. I can double the dose if I'm sick.
Correct Answer: B
Rationale: Corticosteroid therapy for Addison's disease requires daily administration to replace deficient hormones and maintain physiological balance.
After the client returns from surgery and resumes eating, the nurse should encourage the client to eat foods from which food group?
- A. Bread and cereals
- B. Milk and cheese
- C. Meat and seafood
- D. Fruit and vegetables
Correct Answer: B
Rationale: Milk and cheese are rich in calcium, essential for clients post-parathyroidectomy to prevent hypocalcemia.