Nokea
When a client informs the nurse that he is experiencing hypoglycemia, the nurse provides immediate intervention by providing:
- A. one commercially prepared glucose tablet
- B. two hard candies
- C. 4-6 ounces of fruit juice
- D. 2-3 teaspoons of honey
Correct Answer: D
Rationale: The correct immediate intervention for hypoglycemia is to provide 10-15 grams of fast-acting simple carbohydrates orally if the client is conscious and able to swallow. This can be achieved by giving 2-3 teaspoons of honey. Honey is a quick source of simple sugars that can rapidly raise blood glucose levels. Commercially prepared glucose tablets or 4-6 ounces of fruit juice are also appropriate options. However, adding sugar to fruit juice is unnecessary as the natural fruit sugar in juice already provides enough simple carbohydrates to raise blood glucose levels. Hard candies are not the best choice for immediate intervention in hypoglycemia as they may not provide a sufficient amount of fast-acting carbohydrates needed to raise blood sugar levels quickly.
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When assessing a client in the Emergency Department whose membranes have ruptured, the nurse notes that the fluid is a greenish color. What is the cause of this greenish coloration?
- A. blood
- B. meconium
- C. hydramnios
- D. caput
Correct Answer: B
Rationale: The correct answer is B: meconium. Greenish amniotic fluid passed when the fetus is in a cephalic (head) presentation might indicate fetal distress. A fetus in the breech presentation passes meconium due to compression on the intestinal tract. Choice A, blood, is incorrect as blood in the amniotic fluid would present as a different color. Choice C, hydramnios, refers to an excess of amniotic fluid and would not cause the greenish coloration. Choice D, caput, is swelling of a newborn's scalp and is not related to the color of the amniotic fluid.
A client comes to the clinic for assessment of his physical status and guidelines for starting a weight-reduction diet. The client's weight is 216 pounds and his height is 66 inches. The nurse identifies the BMI (body mass index) as:
- A. Within normal limits, so a weight-reduction diet is unnecessary.
- B. Lower than normal, so education about nutrient-dense foods is needed.
- C. Indicating obesity because the BMI is 35.
- D. Indicating overweight status because the BMI is 27.
Correct Answer: C
Rationale: Obesity is defined by a BMI of 30 or more with no co-morbid conditions. Body Mass Index (BMI) is calculated by utilizing a chart or nomogram that plots height and weight. In this case, the client's BMI is calculated as 35, indicating obesity. A BMI of 27 falls within the overweight range, not obesity (which starts at 30). Choices A and B are incorrect because a BMI of 35 indicates obesity, not normal limits or being lower than normal. Therefore, the correct answer is C, indicating obesity based on the BMI calculation.
A nurse is caring for a client with an elevated urine osmolarity. The nurse should assess the client for:
- A. fluid volume excess.
- B. hyperkalemia.
- C. hypercalcemia.
- D. fluid volume deficit.
Correct Answer: D
Rationale: Elevated urine osmolarity indicates that the urine is concentrated, suggesting the body is trying to conserve water. This commonly occurs in conditions like dehydration or fluid volume deficit. Assessing the client for fluid volume excess, hyperkalemia, or hypercalcemia would not be the priority in this situation. Therefore, the correct answer is to assess the client for fluid volume deficit. Fluid volume excess is characterized by decreased urine osmolarity, while hyperkalemia and hypercalcemia are related to electrolyte imbalances and would not directly cause elevated urine osmolarity.
One of the major functions of the kidneys in maintaining normal fluid balance is:
- A. the manufacture of antidiuretic hormone.
- B. the regulation of calcium and phosphate balance.
- C. the regulation of the pH of the extracellular fluid.
- D. the control of aldosterone levels.
Correct Answer: C
Rationale: The correct answer is 'the regulation of the pH of the extracellular fluid.' The kidneys play a crucial role in maintaining normal fluid balance by regulating extracellular fluid and osmolarity through selective retention and excretion of fluids. Additionally, they regulate the pH of the extracellular fluid by retaining hydrogen ions and excreting metabolic wastes and toxic substances. Choice A is incorrect because antidiuretic hormone (ADH) is manufactured by the pituitary gland, not the kidneys. Choice B is incorrect as the regulation of calcium and phosphate balance is primarily controlled by the parathyroid gland. Choice D is incorrect as aldosterone levels are controlled by the adrenal glands, not the kidneys.
The LPN is preparing to ambulate a client post total knee replacement. Which of the following actions should the nurse perform prior to ambulating the client?
- A. Assist the client to a sitting position at the edge of the bed
- B. Have the client march in place for 30 seconds
- C. Have the client raise his arms above his head
- D. Ask the client the last time he fell
Correct Answer: A
Rationale: The correct action to perform before ambulating a client post total knee replacement is to assist the client to a sitting position at the edge of the bed. This step is crucial to prevent orthostatic hypotension and ensure the client is ready to stand and walk safely. Having the client march in place or raise his arms above his head are not necessary preparations for ambulation. While knowing about the client's fall history is important for safety reasons, it is not the priority action immediately before ambulating the client.