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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The client is one (1) hour postoperative thyroidectomy. Which intervention should the nurse implement?
- A. Check the posterior neck for bleeding.
- B. Assess the client for the Chvostek's sign.
- C. Monitor the client's serum calcium level.
- D. Change the client's surgical dressing.
Correct Answer: A
Rationale: Checking for bleeding on the posterior neck prevents hematoma, a critical post-thyroidectomy complication. Chvostek’s, calcium, and dressing changes are secondary.
An elderly woman has been recently diagnosed as having Type 2 diabetes. Which of the following complaints that she has is most likely to be related to the diagnosis of diabetes mellitus?
- A. Pruritus vulvae
- B. Cough
- C. Eructation
- D. Singultus
Correct Answer: A
Rationale: Pruritus vulvae is common in diabetes due to yeast infections from elevated glucose levels.
Which instruction by the nurse concerning the test procedure is most accurate?
- A. You need to eat a large meal just before the test.
- B. You can drink coffee or tea in the morning before the test.
- C. You will be given a sweetened drink before the test.
Correct Answer: C
Rationale: A glucose tolerance test involves administering a sweetened drink to assess the body's response to glucose.
The nursing assistant reports to the nurse that the client's blood glucose reading is 58 mg/dL. What is the most appropriate nursing action at this time?
- A. The nurse is the need to be a condition.
- B. Give the client 1/4 cup of sweet fruit juice.
- C. Report the client's symptoms to the physician.
- D. Perform a complete head-to-toe assessment.
Correct Answer: B
Rationale: A blood glucose of 58 mg/dL with symptoms indicates hypoglycemia, requiring immediate administration of a fast-acting carbohydrate like fruit juice.
The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse?
- A. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation.
- B. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22.
- C. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28.
- D. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.
Correct Answer: C
Rationale: Addison’s with hypotension (80/45), tachycardia (124), and lethargy suggests adrenal crisis, requiring an experienced nurse. Ventilator care, stable Cushing’s, and post-thyroidectomy are less acute.