What are the key interventions in managing a patient with diabetic ketoacidosis (DKA)?
- A. Administer insulin and fluids
- B. Administer oral hypoglycemics
- C. Administer glucagon
- D. Administer insulin and monitor blood glucose
Correct Answer: A
Rationale: The correct intervention in managing a patient with diabetic ketoacidosis (DKA) is to administer insulin and fluids. Insulin is crucial to correct hyperglycemia, while fluids are important to address dehydration. Administering oral hypoglycemics (Choice B) is not appropriate in the management of DKA as the patient may not be able to absorb oral medications due to gastrointestinal issues. Glucagon (Choice C) is not indicated in the treatment of DKA. Although monitoring blood glucose (Choice D) is important, it is not the sole key intervention for managing DKA; administering insulin and fluids are the primary interventions.
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What are the signs and symptoms of opioid withdrawal, and how should they be managed?
- A. Nausea, sweating, and increased heart rate; manage with methadone
- B. Pain and restlessness; manage with naloxone
- C. Hallucinations and muscle cramps; manage with clonidine
- D. Severe vomiting and seizures; manage with benzodiazepines
Correct Answer: A
Rationale: The signs and symptoms of opioid withdrawal include nausea, sweating, and increased heart rate. Methadone is commonly used to manage opioid withdrawal symptoms by alleviating them. Choice B, managing with naloxone, is incorrect as naloxone is primarily used for opioid overdose reversal, not withdrawal. Choice C, managing with clonidine, is incorrect as clonidine is used to manage some symptoms of withdrawal, such as anxiety, agitation, and hypertension, but not hallucinations. Choice D, managing with benzodiazepines, is incorrect as benzodiazepines are not typically used as first-line treatment for opioid withdrawal; they may be considered in specific cases but are not a standard approach.
How should a healthcare provider assess a patient for fluid overload?
- A. Monitor weight and assess for shortness of breath
- B. Auscultate lung sounds and monitor blood pressure
- C. Assess for edema in the extremities
- D. Assess for jugular venous distension
Correct Answer: A
Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.
What is the most appropriate response when a client wants to discontinue dialysis?
- A. Ask the client why they want to discontinue.
- B. Instruct the client to focus on self-care.
- C. Offer to call the provider to cancel dialysis.
- D. Seek clarification and establish understanding.
Correct Answer: D
Rationale: When a client expresses the desire to discontinue dialysis, the most appropriate response is to seek clarification and establish understanding. This approach allows the healthcare provider to comprehend the client's concerns, provide support, and engage in a collaborative decision-making process. Choice A, asking the client why they want to discontinue, can be perceived as confrontational and may not effectively address the underlying reasons. Instructing the client to focus on self-care (Choice B) may overlook the client's autonomy and decision-making capacity. Offering to call the provider to cancel dialysis (Choice C) does not actively involve the client in the decision-making process or address their concerns adequately.
A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?
- A. Providing care in the hallway
- B. Reporting client information in the hallway
- C. Helping another client use the restroom
- D. Feeding the client too quickly
Correct Answer: B
Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.
A nurse is providing discharge instructions to a client with home oxygen therapy. Which of the following is essential for safety?
- A. Allow the client to smoke in designated outdoor areas
- B. Place the oxygen equipment 10 feet away from any open flames
- C. Keep oxygen tanks upright at all times
- D. Restrict fluid intake while using oxygen
Correct Answer: C
Rationale: The correct answer is to keep oxygen tanks upright at all times. This is essential for safety as it prevents the tanks from falling and causing injury. Allowing the client to smoke in designated outdoor areas (Choice A) is unsafe as smoking near oxygen equipment can lead to a fire. Placing the oxygen equipment 10 feet away from any open flames (Choice B) is important to prevent fire hazards, but keeping the tanks upright is more directly related to preventing injuries. Restricting fluid intake while using oxygen (Choice D) is not necessary for safety in home oxygen therapy.