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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How does the nurse expect the urine that is collected for a routine urinalysis to appear?
- A. Tea-colored
- B. Pale yellow
- C. Goldless
- D. Light pink
Correct Answer: B
Rationale: In diabetes insipidus, the urine is typically dilute and pale yellow due to the large volume of water excreted.
The nurse is admitting the client tentatively diagnosed with possible hyperaldosteronism. What should be the nurse's priority?
- A. Prepare for a computed tomography (CT) scan
- B. Give prn prescribed analgesic to treat headache
- C. Obtain an ECG to evaluate for dysrhythmias
- D. Assess for generalized weakness and fatigue
Correct Answer: C
Rationale: Obtaining an ECG is priority to detect dysrhythmias from hypokalemia caused by potassium wasting in hyperaldosteronism.
The client diagnosed with type 1 diabetes has a glycosylated hemoglobin (A1c) of 8.1%. Which interpretation should the nurse make based on this result?
- A. This result is below normal levels.
- B. This result is within acceptable levels.
- C. This result is above recommended levels.
- D. This result is dangerously high.
Correct Answer: C
Rationale: An A1c of 8.1% is above the recommended target (<7% for most diabetics), indicating poor glycemic control. It is not normal, acceptable, or dangerously high (e.g., >10%).
The client is admitted to the intensive care department diagnosed with myxedema coma. Which assessment data warrant immediate intervention by the nurse?
- A. Serum blood glucose level of 74 mg/dL.
- B. Pulse oximeter reading of 90%.
- C. Telemetry reading showing sinus bradycardia.
- D. The client is lethargic and sleeps all the time.
Correct Answer: B
Rationale: A pulse oximetry of 90% indicates hypoxia, requiring immediate intervention in myxedema coma. Normal glucose, bradycardia, and lethargy are expected.
When the client practices self-administration of the insulin, which action is correct?
- A. Piercing the skin at a 30-degree angle
- B. Using a syringe calibrated in minims
- C. Using a 29-gauge needle on the syringe
- D. Rotating abdominal sites for each injection
Correct Answer: D
Rationale: Rotating abdominal sites prevents lipodystrophy and ensures consistent insulin absorption.