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When directing the nursing assistant to weigh the client, which instruction is most important for obtaining accurate data?
- A. Have the client stand on a bedside scale.
- B. Weigh the client at the same time each day.
- C. Ask that slippers be removed when being weighed.
- D. Ask about the client's pre-disease weight.
Correct Answer: B
Rationale: Weighing the client at the same time each day ensures consistency and accounts for daily fluctuations in weight due to meals, hydration, or other factors.
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An adult with myxedema is started on thyroid replacement therapy and is discharged. The client returns to the doctor's office one week later. Which statement that the client makes is most indicative of an adverse reaction to the medication?
- A. My chest hurt when I was sweeping the floor this morning.'
- B. I had severe cramps last night.'
- C. I am losing weight.'
- D. My pulse rate has been more rapid lately.'
Correct Answer: A
Rationale: Chest pain during activity suggests angina, a potential adverse effect of thyroid replacement therapy due to increased metabolic demand.
The nurse administers a usual morning dose of 4 units of regular insulin and 8 units of NPH insulin at 7:30 am to the client with a blood glucose level of 110 mg/dL. Which statements regarding the client's insulin are correct?
- A. The onset of the regular insulin will be at 7:45 am and the peak at 1:00 pm.
- B. The onset of the regular insulin will be at 8:00 am and the peak at 10:00 am.
- C. The onset of the NPH insulin will be at 8:00 am and the peak at 10:00 am.
- D. The onset of the NPH insulin will be at 12:30 pm and the peak at 11:30 pm.
Correct Answer: B
Rationale: The onset of regular insulin (short acting) is one-half to 1 hour, and the peak is 2 to 3 hours. The onset of NPH insulin (intermediate acting) is 2 to 4 hours, and the peak is 4 to 12 hours.
Which nursing interventions are most appropriate for nursing in the health of a client with Cushing's syndrome? Select all that apply.
- A. Have the client sleep on a convoluted (egg-crate) foam mattress.
- B. Ambulate the client at frequent intervals.
- C. Advise the client to ask for assistance when getting up.
- D. Offer high-carbohydrate nourishment.
- E. Check the client frequently for suicidal ideation.
- F. Instruct the client to wear loose-fitting clothing.
Correct Answer: A,C,E,F
Rationale: These interventions address skin breakdown, fall risk, mood changes, and comfort in Cushing's syndrome.
The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply.
- A. Maintain adequate ventilation.
- B. Assess fluid volume status.
- C. Administer intravenous potassium.
- D. Check for urinary ketones.
- E. Monitor intake and output.
Correct Answer: A,B,D,E
Rationale: Ventilation, fluid status, ketone checks, and I&O monitoring manage DKA’s acidosis, dehydration, and ketosis. Potassium is given only if low, not routinely.
At the beginning of thyroid replacement therapy after a thyroidectomy, the nurse must monitor the client closely for side effects. Which findings would the nurse expect to detect if the client is receiving more thyroid hormone replacement than required? Select all that apply.
- A. Hyperglycemia
- B. Tachycardia
- C. Insomnia
- D. Hirsutism
- E. Hypertension
Correct Answer: B,C,E
Rationale: Excess thyroid hormone can cause tachycardia, insomnia, and hypertension due to increased metabolic rate.