Nokea
The nurse should teach the diabetic client that which of the following is the most common symptom of hypoglycemia?
- A. Nervousness.
- B. Anorexia.
- C. Kussmaul's respirations.
- D. Bradycardia.
Correct Answer: A
Rationale: Nervousness is a common symptom of hypoglycemia due to the body's stress response to low blood glucose levels.
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A nurse is assessing a client who has been admitted with a diagnosis of an obstruction in the small intestine. The nurse should assess the client for? Select all that apply.
- A. Projectile vomiting.
- B. Significant abdominal distention.
- C. Copious diarrhea.
- D. Rapid onset of dehydration.
- E. Increased bowel sounds.
Correct Answer: A,B,D,E
Rationale: Small intestinal obstruction can cause projectile vomiting (A), abdominal distention (B), rapid dehydration (D) due to fluid loss, and increased bowel sounds (E) proximal to the obstruction. Copious diarrhea (C) is less likely as stool passage is blocked. CN: Physiological adaptation; CL: Analyze
The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by
- A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third.
- B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion.
- C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers.
- D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection.
Correct Answer: A
Rationale: The vastus lateralis is correctly located by dividing the thigh into thirds between the greater trochanter and knee, with the middle third being the injection site.
Upon assessment of third degree heart block on the monitor, the nurse should first:
- A. Call a code.
- B. Begin cardiopulmonary resuscitation.
- C. Have transcutaneous pacing ready at the bedside.
- D. Prepare for defibrillation.
Correct Answer: C
Rationale: Third-degree heart block may require pacing. Having transcutaneous pacing ready is the first step to manage symptomatic bradycardia.
A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
- A. Check that the family is comfortable.
- B. Assess vital signs following the use of morphine.
- C. Dim the lights in the room.
- D. Increase nasal oxygen from 2 to 3 L.
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
What should the nurse assess first in a client with a recent head injury?
- A. Pupil response.
- B. Blood pressure.
- C. Pain level.
- D. Reflexes.
Correct Answer: A
Rationale: Pupil response is assessed first to detect neurological changes, such as increased intracranial pressure, in a head injury.