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What is a key intervention for a patient with diabetic ketoacidosis (DKA)?
- A. Administering insulin
- B. Administering IV fluids
- C. Administering oral glucose
- D. Administering oral fluids
Correct Answer: A
Rationale: Administering insulin is a crucial intervention for a patient with diabetic ketoacidosis (DKA) because it helps in managing hyperglycemia and ketosis by promoting the uptake of glucose by cells and inhibiting the production of ketones. IV fluids are necessary to correct dehydration and electrolyte imbalances commonly seen in DKA but are not the primary treatment for the condition. Administering oral glucose would exacerbate hyperglycemia in a patient with DKA, while administering oral fluids alone would not effectively address the underlying metabolic disturbances seen in DKA.
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A client is to have a transsphenoidal hypophysectomy to remove a large, invasive pituitary tumor. The nurse should instruct the client that the surgery will be performed through an incision in the:
- A. Back of the mouth.
- B. Nose.
- C. Sinus channel below the right eye.
- D. Upper gingival mucosa in the space between the upper gums and lip.
Correct Answer: D
Rationale: The correct answer is D: Upper gingival mucosa in the space between the upper gums and lip. A transsphenoidal hypophysectomy involves accessing the pituitary gland through an incision in the upper gingival mucosa, providing direct access to the pituitary gland without external scars. Choices A, B, and C are incorrect because the surgery is not performed through the back of the mouth, the nose, or the sinus channel below the right eye. It is crucial for the client to understand the specific location of the incision to ensure accurate preoperative education and expectations.
After the administration of t-PA, what should the nurse do?
- A. Observe the client for chest pain.
- B. Monitor for fever.
- C. Review the 12-lead electrocardiogram (ECG).
- D. Auscultate breath sounds.
Correct Answer: A
Rationale: After the administration of t-PA, the nurse should observe the client for chest pain. Chest pain post t-PA administration could indicate reocclusion of the coronary artery, a serious complication that requires immediate intervention. Monitoring for fever (choice B) is not specifically associated with t-PA administration. While reviewing the 12-lead ECG (choice C) is important for assessing cardiac function, it may not be the immediate priority right after t-PA administration. Auscultating breath sounds (choice D) is important for assessing respiratory status but is not the most crucial assessment following t-PA administration.
When providing care for an unconscious client who has seizures, which nursing intervention is most essential?
- A. Ensure oral suction is available.
- B. Maintain the client in a semi-Fowler's position.
- C. Provide frequent mouth care.
- D. Keep the room at a comfortable temperature.
Correct Answer: A
Rationale: During seizures in an unconscious client, ensuring oral suction is available is crucial to managing secretions and preventing aspiration. This intervention helps maintain a clear airway and reduce the risk of complications. Maintaining the client in a semi-Fowler's position (Choice B) may be important for airway management but is not as critical as having oral suction ready. Providing frequent mouth care (Choice C) and keeping the room at a comfortable temperature (Choice D) are important aspects of overall care but are not as urgently needed as ensuring oral suction for managing secretions during seizures.
Which of the following is a key symptom of hyperthyroidism?
- A. Weight loss.
- B. Weight gain.
- C. Tachycardia.
- D. Dry skin.
Correct Answer: A
Rationale: The correct answer is weight loss. In hyperthyroidism, there is an excess production of thyroid hormones leading to an increased metabolic rate. This increased metabolism can result in weight loss despite normal or increased appetite. Choice B (Weight gain) is more commonly associated with hypothyroidism where the metabolic rate is decreased. Choice C (Tachycardia) is another common symptom of hyperthyroidism due to the effects of thyroid hormones on the heart, causing an increased heart rate. Choice D (Dry skin) is not a typical symptom of hyperthyroidism; instead, it is more commonly associated with hypothyroidism.
When conducting discharge teaching for a client diagnosed with diverticulosis, which diet instruction should the nurse include?
- A. Eat a high-fiber diet and increase fluid intake.
- B. Have small frequent meals and sit up for at least two hours after meals.
- C. Eat a bland diet and avoid spicy foods.
- D. Eat a soft diet with increased intake of milk and milk products.
Correct Answer: A
Rationale: A high-fiber diet with increased fluid intake is the most appropriate diet instruction for a client diagnosed with diverticulosis. High-fiber foods help prevent constipation and promote bowel regularity, reducing the risk of complications such as diverticulitis. Adequate fluid intake is crucial to soften stool and aid in digestion. Choice B, having small frequent meals and sitting up after meals, may be beneficial for some gastrointestinal conditions but is not specific to diverticulosis. Choice C, eating a bland diet and avoiding spicy foods, is not necessary for diverticulosis management. Choice D, consuming a soft diet with increased milk and milk products, may worsen symptoms in diverticulosis due to the potential for increased gas production and bloating.