Nokea
The nurse should............ because...........
- A. obtain an order to change the intravenous fluids (IV)
- B. pause the regular insulin infusion
- C. continue the regular insulin infusion
- D. the client's glucose level warrants a change in IV fluids.
- E. the glucose level is dropping too fast.
- F. the glucose level is dropping at a therapeutic level.
Correct Answer: A, D
Rationale: In DKA, as glucose drops, IV fluids may need adjustment (e.g., to dextrose-containing fluids) to prevent hypoglycemia while continuing insulin to resolve acidosis.
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The nurse is educating a diabetic client regarding foot care. Which of the following statements by the client indicates a correct understanding of the nurse's instructions?
- A. I need to check my feet daily for sores, blisters, dry skin, and cuts.
- B. I need to wash my feet daily and keep them dry.
- C. If I get sores or blisters on my feet, I should not pop them.
- D. I need to apply cream to my heels and between my toes daily.
- E. I should wear tight compression socks on both feet.
Correct Answer: A, B, C
Rationale: Daily checks, washing, and keeping feet dry prevent complications. Not popping sores avoids infection. Cream between toes risks fungal growth, and tight socks impair circulation.
The nurse is performing a physical assessment on a client with Cushing's disease. Which assessment findings should the nurse expect?
- A. Hypotension
- B. Acne
- C. Hirsutism
- D. Buffalo hump
- E. Truncal obesity
Correct Answer: B, C, D, E
Rationale: Cushing's disease from excess cortisol causes acne, hirsutism (excess hair), buffalo hump, and truncal obesity due to fat redistribution. Hypertension, not hypotension, is typical.
The nurse is caring for a client who has adrenal insufficiency (Addison's disease). Which of the following interventions would be a priority?
- A. Administer prescribed hydrocortisone
- B. Offer salty snacks and water
- C. Assess skin integrity
- D. Encourage frequent rest periods
Correct Answer: A
Rationale: Adrenal insufficiency causes cortisol deficiency, leading to hypotension and weakness. Administering hydrocortisone is critical to replace cortisol and stabilize the client. Salty snacks, skin checks, and rest are supportive but not the priority.
A nurse is caring for a client receiving metformin. Which of the following laboratory data should be reported to the provider?
- A. Decreased blood urea nitrogen (BUN) level
- B. Decreased glomerular filtration rate (GFR)
- C. Decreased fasting plasma glucose
- D. Decreased hemoglobin A1C
Correct Answer: B
Rationale: A decreased GFR indicates renal impairment, increasing the risk of metformin-associated lactic acidosis, requiring immediate reporting. Decreased BUN, glucose, and HbA1c are expected or less urgent.
The nurse caring for a diabetes mellitus client obtained a scheduled capillary blood glucose. The result indicated 40 mg/dL (2.22 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The client reports no symptoms. The initial action of the nurse should be which of the following?
- A. Document the finding in the medical record
- B. Repeat the capillary blood glucose test to validate the result
- C. Administer 15 grams of a quick-acting carbohydrate
- D. Administer 1 mg of glucagon subcutaneously
Correct Answer: B
Rationale: A glucose of 40 mg/dL is critically low, even without symptoms. Repeating the test validates the result, ensuring accuracy before treatment to avoid unnecessary intervention.