Nokea
Which assessment data indicate the client diagnosed with diabetic ketoacidosis is responding to the medical treatment?
- A. The client has tented skin turgor and dry mucous membranes.
- B. The client is alert and oriented to date, time, and place.
- C. The client's ABG results are pH 7.29, PaCO2 44, HCO3 15.
- D. The client's serum potassium level is 3.3 mEq/L.
Correct Answer: B
Rationale: Alertness and orientation indicate resolving DKA, as cerebral function improves. Persistent dehydration, acidosis (pH 7.29), and hypokalemia are not signs of improvement.
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Which client action indicates a need for further teaching about insulin administration?
- A. Using a new needle for each injection
- B. Storing insulin in the refrigerator
- C. Checking blood glucose before injecting
- D. Injecting insulin into a lipodystrophic area
Correct Answer: D
Rationale: Injecting insulin into a lipodystrophic area can impair absorption, indicating a need for further teaching on site rotation.
The nurse obtains a fingerstick blood glucose reading of 48 mg/dL for the client with type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse's best immediate intervention?
- A. Administer the insulin that is due now.
- B. Call the lab for a STAT serum glucose level.
- C. Have the client choose foods for a meal now.
- D. Provide juice with 15 grams of carbohydrates.
Correct Answer: D
Rationale: Hypoglycemia is treated with 15 to 20 g of a simple (fast-acting) carbohydrate, such as 4 to 6 oz of fruit juice or 8 oz of low-fat milk.
The nurse is planning the care of a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should be implemented? Select all that apply.
- A. Restrict fluids per health-care provider order.
- B. Assess level of consciousness every two (2) hours.
- C. Provide an atmosphere of stimulation.
- D. Monitor urine and serum osmolality.
- E. Weigh the client every three (3) days.
Correct Answer: A,B,D
Rationale: Fluid restriction, frequent consciousness checks, and osmolality monitoring manage SIADH’s hyponatremia and fluid overload. Stimulation is inappropriate, and weighing every 3 days is too infrequent.
The nurse caring for a client diagnosed with cancer of the pancreas writes the problem of 'altered nutrition: less than body requirements.' Which collaborative intervention should the nurse include in the plan of care?
- A. Continuous feedings via (PEG) tube.
- B. Have the family bring in foods from home.
- C. Assess for food preferences.
- D. Refer to the dietitian.
Correct Answer: D
Rationale: Referring to a dietitian ensures specialized nutritional planning for pancreatic cancer, addressing malabsorption and weight loss. PEG feedings, family foods, and preferences are secondary.
The nurse is preparing to discharge the client following a unilateral adrenalectomy to treat hyperaldosteronism caused by an adenoma. Which instruction should be included in this client's discharge teaching?
- A. Avoid foods high in potassium
- B. Self-monitor blood pressure daily
- C. Stop drugs taken before adrenalectomy
- D. Carry epinephrine for emergency use
Correct Answer: B
Rationale: Self-monitoring BP is necessary as hypertension may persist in 20% of clients post-adrenalectomy.