Nokea
Which client problem has priority for the client diagnosed with acute pancreatitis?
- A. Risk for fluid volume deficit.
- B. Alteration in comfort.
- C. Imbalanced nutrition: less than body requirements.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in acute pancreatitis due to vomiting and third-spacing, risking hypovolemia. Pain, nutrition, and knowledge are secondary.
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A client is admitted to the hospital with recently diagnosed Type I diabetes mellitus and is to have fasting blood work drawn this morning. At 7:00 A.M., the lab has not arrived to draw the blood. The client's dose of regular insulin is scheduled for 7:30 A.M. What is the best action for the nurse to take?
- A. Give the insulin as ordered
- B. Withhold the insulin until the lab comes and the client will be eating within 15 to 30 minutes
- C. Withhold the insulin until the blood has been drawn and the client has eaten
- D. Do not administer insulin until the blood work has been drawn and the results have been called back to the unit
Correct Answer: C
Rationale: Withholding insulin until blood is drawn and the client has eaten prevents hypoglycemia during fasting blood work.
When the client asks why a diabetic relative cannot take insulin orally, what is the best answer?
- A. Insulin is inactivated by digestive enzymes.
- B. Insulin is absorbed too quickly in the stomach.
- C. Insulin is irritating to the gastric mucosa.
- D. Insulin is incompatible with many foods.
Correct Answer: A
Rationale: Insulin is a protein that is broken down by digestive enzymes, rendering it ineffective if taken orally.
The client diagnosed with a pituitary tumor developed syndrome of inappropriate antidiuretic hormone (SIADH). Which interventions should the nurse implement?
- A. Assess for dehydration and monitor blood glucose levels.
- B. Assess for nausea and vomiting and weigh daily.
- C. Monitor potassium levels and encourage fluid intake.
- D. Administer vasopressin IV and conduct a fluid deprivation test.
Correct Answer: B
Rationale: Nausea/vomiting and daily weights monitor SIADH complications (e.g., hyponatremia, fluid overload). Dehydration is unlikely, potassium is less critical, and vasopressin worsens SIADH.
The client admitted to rule out pancreatic islet tumors complains of feeling weak, shaky, and sweaty. Which priority intervention should be implemented by the nurse?
- A. Start an IV with D5W.
- B. Notify the health-care provider.
- C. Perform a bedside glucose check.
- D. Give the client some orange juice.
Correct Answer: C
Rationale: Weakness, shakiness, and sweating suggest hypoglycemia from an insulinoma; a glucose check confirms this, guiding treatment. IV D5W, HCP notification, and juice follow confirmation.
Which sign is most suggestive that a client with type 2 diabetes is developing hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. The client's serum glucose level is 650 mg/dL.
- B. The client's urinary output is 3,000 mL/24 hours.
- C. The client's skin is cool and moist.
- D. The client's urine contains acetone.
Correct Answer: A
Rationale: A serum glucose level of 650 mg/dL is characteristic of HHNS, indicating severe hyperglycemia.