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What are the signs of hypoglycemia, and how should they be managed?
- A. Sweating, trembling; administer glucose
- B. Headache, confusion; administer insulin
- C. Dizziness, fatigue; administer glucose
- D. Increased heart rate; provide a high-sugar snack
Correct Answer: A
Rationale: The correct signs of hypoglycemia are sweating and trembling. These should be managed by administering glucose to raise blood sugar levels. Headache, confusion, dizziness, fatigue, or increased heart rate are not typical signs of hypoglycemia. Administering insulin in response to hypoglycemia would further lower blood sugar levels, exacerbating the condition.
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A nurse is collecting data from a client who has myasthenia gravis (MG). Which of the following images should the nurse identify as an indication that the client is experiencing ptosis?
- A. Drooping eyelids
- B. Unequal pupils
- C. Facial twitching
- D. Facial droop
Correct Answer: A
Rationale: The correct answer is A: 'Drooping eyelids.' Ptosis, characterized by drooping of the eyelid, is a classic symptom seen in myasthenia gravis. This occurs due to muscle weakness, particularly in the muscles that control eyelid movement. Choice B, 'Unequal pupils,' is not associated with ptosis and may indicate other neurological issues. Choice C, 'Facial twitching,' is not a typical sign of ptosis but could be related to other conditions like nerve irritation. Choice D, 'Facial droop,' is more commonly seen in conditions affecting the facial nerve, like Bell's palsy, and is not a characteristic feature of myasthenia gravis.
A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence?
- A. Request an occupational therapy consult to determine the need for assistive devices
- B. Assign assistive personnel to perform self-care tasks for the client
- C. Instruct the client to focus on gradually resuming self-care tasks
- D. Ask the client if a family member is available to assist with his care
Correct Answer: C
Rationale: Instructing the client to focus on gradually resuming self-care tasks is the most appropriate strategy to promote independence following an acute myocardial infarction. This approach allows the client to regain confidence and control over their self-care activities without feeling overwhelmed. Requesting an occupational therapy consult (Choice A) may be beneficial but is not the immediate solution to promote independence. Assigning assistive personnel (Choice B) to perform tasks for the client does not encourage independence. Asking if a family member is available for assistance (Choice D) does not directly promote the client's independence.
A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?
- A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
- B. Reinforcing teaching with a client who is learning to walk with a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.
A client has developed phlebitis at the IV site. What is the most appropriate next step?
- A. Apply a warm compress over the IV site
- B. Notify the provider and discontinue the IV infusion
- C. Increase the IV flow rate to clear the blockage
- D. Elevate the extremity and apply an ice pack
Correct Answer: B
Rationale: Phlebitis, inflammation of a vein, is a complication that requires prompt action. The most appropriate next step is to discontinue the IV infusion and notify the healthcare provider. Applying a warm compress, increasing the IV flow rate, or applying an ice pack are not appropriate interventions for phlebitis. Warm compresses may worsen inflammation, increasing the IV flow rate could exacerbate the condition, and ice packs are not recommended for phlebitis.
What are the signs and symptoms of fluid overload, and how should a nurse manage this condition?
- A. Edema, weight gain, shortness of breath
- B. Fever, cough, chest pain
- C. Increased heart rate, low blood pressure
- D. Increased blood pressure, jugular venous distention
Correct Answer: A
Rationale: Fluid overload manifests as edema, weight gain, and shortness of breath. These symptoms occur due to an excess of fluid in the body. Managing fluid overload involves interventions such as monitoring fluid intake and output, adjusting diuretic therapy, restricting fluid intake, and collaborating with healthcare providers to address the underlying cause. Choices B, C, and D are incorrect because they do not represent typical signs of fluid overload. Fever, cough, chest pain, increased heart rate, low blood pressure, increased blood pressure, and jugular venous distention are not primary indicators of fluid overload.