Nokea
What is the primary nursing intervention for a patient experiencing hypoglycemia?
- A. Administer IV fluids
- B. Check blood sugar levels
- C. Provide oral glucose
- D. Recheck blood sugar levels in 15 minutes
Correct Answer: D
Rationale: The correct answer is to recheck blood sugar levels in 15 minutes. This intervention is crucial to ensure that the hypoglycemia has been effectively corrected after the initial treatment. Administering IV fluids may be necessary in cases of severe dehydration but is not the primary intervention for hypoglycemia. Checking blood sugar levels is important, but the primary intervention should focus on treating the low blood sugar levels first, which is done by providing oral glucose. However, the most critical step after providing initial treatment is to recheck blood sugar levels to confirm that they have improved to safe levels.
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A client with a new colostomy requires care planning by a nurse. Which of the following interventions should the nurse include in the plan of care?
- A. Change the ostomy pouch every 4 to 7 days.
- B. Empty the ostomy pouch when it is half full.
- C. Apply a skin barrier around the stoma.
- D. Cleanse the peristomal skin with alcohol.
Correct Answer: A
Rationale: The correct answer is to change the ostomy pouch every 4 to 7 days. This practice helps prevent skin irritation and leakage by maintaining a clean and secure seal around the stoma. Option B is incorrect because it is more important to change the pouch regularly rather than emptying it when half full. Option C is incorrect as applying a skin barrier is typically done during the initial application of the pouch, not during regular changes. Option D is incorrect because alcohol can be too harsh for the peristomal skin and can cause irritation.
Which lab value is most critical to monitor in a patient receiving insulin therapy?
- A. Monitor blood glucose
- B. Monitor potassium levels
- C. Monitor calcium levels
- D. Monitor sodium levels
Correct Answer: A
Rationale: The correct answer is to monitor blood glucose levels. When a patient is receiving insulin therapy, it is crucial to monitor blood glucose levels regularly to prevent hypoglycemia, a potential side effect of insulin therapy. Monitoring potassium, calcium, or sodium levels is important for different medical conditions or treatments and is not directly related to insulin therapy.
A nurse is caring for a client who is 32 weeks pregnant and has cardiac disease. Which of the following positions should the nurse place the client in to promote optimal cardiac output?
- A. Semi-Fowler's
- B. Supine with head elevated
- C. Left lateral
- D. Right lateral
Correct Answer: C
Rationale: The correct answer is C: Left lateral. Placing the client in the left lateral position helps promote optimal cardiac output during pregnancy by avoiding pressure on the vena cava. This position improves venous return to the heart and subsequently cardiac output. Option A, Semi-Fowler's position, may not be the best choice for a client with cardiac disease as it does not alleviate pressure on the vena cava. Option B, supine with head elevated, can also compress the vena cava, reducing cardiac output. Option D, right lateral position, does not provide the same benefits as the left lateral position for cardiac output during pregnancy.
A nurse is providing discharge instructions to a client who is postoperative following a total hip arthroplasty. Which of the following client statements indicates a need for further teaching?
- A. I will avoid crossing my legs when sitting.
- B. I will use a raised toilet seat.
- C. I will sleep on my affected side.
- D. I will perform leg exercises every hour while awake.
Correct Answer: C
Rationale: The correct answer is C. Sleeping on the affected side could increase the risk of dislocation following a hip arthroplasty. It is essential for the client to avoid sleeping on the surgical side to prevent complications. Choices A, B, and D are correct statements that promote proper postoperative care and reduce the risk of complications. Avoiding crossing legs when sitting, using a raised toilet seat for proper positioning, and performing leg exercises regularly help in the recovery process and prevent complications.
A client with a new diagnosis of hypertension is receiving discharge teaching. Which statement by the client indicates an understanding of the teaching?
- A. I will take my medication only when I feel dizzy.
- B. I will check my blood pressure at least once a week.
- C. I will limit my saturated fat intake to 7% of daily calories.
- D. I will take my medication only when I have symptoms.
Correct Answer: C
Rationale: The correct answer is C because limiting saturated fat intake to 7% of daily calories is a crucial component of the dietary management for hypertension. This dietary modification helps reduce the risk of cardiovascular complications. Choices A, B, and D are incorrect. Choice A is incorrect because medication adherence should not be based on symptoms like dizziness. Choice B is inadequate as blood pressure monitoring should be more frequent, preferably daily, for effective management of hypertension. Choice D is incorrect because medication for hypertension should be taken consistently as prescribed, not just when symptoms occur.