Nokea
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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During the admission of a client with a latex allergy, which of the following supplies has the potential to contain latex?
- A. Urinary catheters
- B. Indwelling catheters
- C. Sterile gloves
- D. Sterile gowns
Correct Answer: A
Rationale: The correct answer is A: Urinary catheters. Urinary catheters often contain latex, which can trigger an allergic reaction in clients with latex allergy. Indwelling catheters (choice B), sterile gloves (choice C), and sterile gowns (choice D) can be latex-free alternatives. However, urinary catheters are more commonly made with latex, making them a higher risk for clients with latex allergies.
A client is learning to use a cane due to left-leg weakness. Which instruction is correct?
- A. Use the cane on the stronger side of the body
- B. Maintain two points of support on the floor at all times
- C. Advance the cane and the strong leg together
- D. Advance the cane 30 to 45 cm with each step
Correct Answer: B
Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.
What is a primary symptom of left-sided heart failure?
- A. Shortness of breath
- B. Edema
- C. Rapid heartbeat
- D. Confusion
Correct Answer: A
Rationale: Shortness of breath is a primary symptom of left-sided heart failure. In this condition, the heart's inability to pump effectively leads to fluid backing up into the lungs, causing difficulty breathing. Edema (swelling), rapid heartbeat, and confusion are more commonly associated with other conditions or right-sided heart failure. Edema is often seen in right-sided heart failure due to fluid accumulation in the body, rapid heartbeat can be a general sign of heart issues, and confusion is more related to decreased brain perfusion in severe heart failure cases.
Which of the following is an early indicator that suctioning is needed for a client with a tracheostomy?
- A. Bradycardia
- B. Hypotension
- C. Irritability
- D. Confusion
Correct Answer: C
Rationale: Irritability is an early indicator that suctioning is needed for a client with a tracheostomy because it can signal discomfort or difficulty breathing due to mucus accumulation, prompting the need for suctioning to clear the airway. Bradycardia (Choice A) and hypotension (Choice B) are not typically early indicators of the need for suctioning in a client with a tracheostomy. Confusion (Choice D) is also not a direct early indicator of the need for suctioning in this context.
A nurse is reviewing the plan of care for a client who is postoperative following a hip replacement. Which of the following interventions should the nurse implement to prevent venous thromboembolism?
- A. Instruct the client to perform ankle pumps
- B. Administer anticoagulant therapy as prescribed
- C. Maintain the client in a prone position
- D. Encourage the client to ambulate as tolerated
Correct Answer: B
Rationale: The correct intervention to prevent venous thromboembolism in a postoperative client following hip replacement is to administer anticoagulant therapy as prescribed. Anticoagulants help prevent blood clots from forming. Instructing the client to perform ankle pumps helps prevent blood clots by promoting circulation. Maintaining the client in a prone position can increase the risk of venous stasis and thrombus formation. Encouraging the client to ambulate as tolerated also helps prevent venous thromboembolism by promoting blood flow and preventing stasis.