Nokea
The nurse's next door neighbor calls. He says he cannot awaken his 21-year-old wife. The nurse notes that the client is unconscious and is having deep respirations. Her breath has a fruity smell to it. The husband says that his wife has been eating and drinking a lot recently and that last night she vomited before lying down. What is the most appropriate action for the nurse to take?
- A. Start cardiopulmonary resuscitation
- B. Get her to a hospital immediately
- C. Try to rouse her by giving her coffee
- D. Give her sweetened orange juice
Correct Answer: B
Rationale: Fruity breath, unconsciousness, and symptoms of polyphagia, polydipsia, and vomiting suggest diabetic ketoacidosis, requiring immediate hospital care.
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Immediately after surgery, the nurse assesses the client for bleeding. Where is the best location to assess for bleeding?
- A. The skull
- B. The nose
- C. The ear canal
- D. The tongue
Correct Answer: B
Rationale: Trans-sphenoidal hypophysectomy is performed through the nasal cavity, so bleeding is most likely to be observed in the nose.
A woman with hypothyroidism asks the nurse why the doctor told her she cannot have a sedative. The nurse's response is based on which of the following facts?
- A. Sedatives potentiate thyroid replacement medication.
- B. Clients with hypothyroidism have increased susceptibility to all sedative drugs.
- C. Sedatives will have a paradoxical effect on clients with hypothyroidism.
- D. Sedatives would cause fluid retention and hypernatremia.
Correct Answer: B
Rationale: Hypothyroidism increases sensitivity to sedatives, risking excessive sedation or respiratory depression.
The nurse observes the client self-administering the medication. Which action indicates that the client is using the medication correctly?
- A. The client shakes the medication vigorously
- B. The client's head is tilted to the side.
- C. The client inverts the drug container.
- D. The client inhales with each spray.
Correct Answer: D
Rationale: For intranasal lypressin, inhaling with each spray ensures proper delivery of the medication to the nasal mucosa.
The client had a total pancreatectomy and splenectomy for cancer of the body of the pancreas. Which discharge instructions should the nurse teach? Select all that apply.
- A. Keep a careful record of intake and output.
- B. Use a stool softener or bulk laxative regularly.
- C. Use correct insulin injection technique.
- D. Take the pain medication before the pain gets too bad.
- E. Sleep with the head of the bed on blocks.
Correct Answer: B,C,D
Rationale: Stool softeners prevent constipation, insulin technique manages post-pancreatectomy diabetes, and proactive pain medication controls discomfort. I&O and elevated bed are unnecessary.
To detect complications of surgery in the immediate postoperative period, which assessment component is most important for the nurse to monitor?
- A. Blood pressure
- B. Urine output
- C. Upperness
- D. Specific gravity
Correct Answer: A
Rationale: Blood pressure monitoring detects adrenal insufficiency or bleeding post-adrenalectomy.