Nokea
The nurse should explain to a client that tolbutamide (Orinase) is effective for diabetics who
- A. can no longer produce any insulin.
- B. produce minimal amounts of insulin.
- C. are unable to administer their injections.
- D. have a sustained decreased blood glucose.
Correct Answer: B
Rationale: oral hypoglycemic agents are administered to type II (non-insulindependent) clients who are able to produce minimal amounts of insulin
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The nurse is assessing a client with a history of diabetes mellitus who is admitted with diabetic ketoacidosis (DKA). Which of the following findings would the nurse expect?
- A. Slow, shallow respirations.
- B. Fruity breath odor.
- C. Bradycardia.
- D. Hypotension.
Correct Answer: B
Rationale: fruity breath odor is a classic sign of DKA due to the presence of acetone
A client hospitalized with renal calculi complains of severe pain in the right flank. In addition to complaints of pain, the nurse can expect to see changes in the client's vital signs that include:
- A. Decreased pulse rate
- B. Increased blood pressure
- C. Decreased respiratory rate
- D. Increased temperature
Correct Answer: B
Rationale: Severe pain from renal calculi can cause increased blood pressure due to sympathetic nervous system activation and stress response.
A client is being treated with internal radiation (brachytherapy). The nurse explains to the client that
- A. visitors should wear gown, gloves, and mask when coming in the room.
- B. visitors are not allowed until the client is no longer receiving radiation therapy.
- C. visitors must stay at least 6 feet away from the client.
- D. visitors should not bring any cards or gifts into the room because they can become radioactive.
Correct Answer: C
Rationale: Brachytherapy requires distance precautions; visitors must stay 6 feet away to minimize radiation exposure. Gowns/masks are not needed, visitors are allowed, and gifts do not become radioactive.
The nurse is providing discharge instructions to the parents of a 6-month-old child with surgical repair for cryptorchidism. Which instruction would NOT be stressed?
- A. observe surgical site for bleeding
- B. enforce bed rest for 2-3 days
- C. palpate scrotum to check testicle location
- D. avoid strenuous activity for at least one month
Correct Answer: B
Rationale: Bed rest for 2-3 days is not typically required for cryptorchidism repair in infants, as recovery is quicker. Other instructions are critical for monitoring and safety.
The nurse is preparing to assist with a lumbar puncture for a client with suspected meningitis. Which of the following positions should the nurse place the client in?
- A. Supine with the head elevated.
- B. Prone with the head turned to one side.
- C. Side-lying with knees flexed to the chest.
- D. Sitting with the back arched.
Correct Answer: C
Rationale: side-lying with knees flexed to the chest maximizes spinal flexion, facilitating access to the subarachnoid space