Nokea
Which electrolyte replacement should the nurse anticipate being ordered by the health-care provider in the client diagnosed with diabetic ketoacidosis (DKA) who has just been admitted to the ICU?
- A. Glucose.
- B. Potassium.
- C. Calcium.
- D. Sodium.
Correct Answer: B
Rationale: DKA causes potassium depletion due to acidosis and diuresis; replacement is anticipated to prevent arrhythmias. Glucose is not an electrolyte, and calcium/sodium are less critical.
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Immediately after surgery, the nurse assesses the client for bleeding. Where is the best location to assess for bleeding?
- A. The skull
- B. The nose
- C. The ear canal
- D. The tongue
Correct Answer: B
Rationale: Trans-sphenoidal hypophysectomy is performed through the nasal cavity, so bleeding is most likely to be observed in the nose.
When developing the client's care plan, which intervention is most appropriate to add?
- A. Encourage the client to use an electric razor.
- B. Tell the client to file rather than cut toenails.
- C. Make sure that the client receives mouth care twice per day.
- D. Advise the client to use deodorant soap when bathing.
Correct Answer: B
Rationale: Filing toenails prevents injury and infection in diabetic clients with poor healing.
The client with chronic alcoholism has chronic pancreatitis and hypomagnesemia. Which data should the nurse assess when administering magnesium sulfate to the client?
- A. Deep tendon reflexes.
- B. Arterial blood gases.
- C. Skin turgor.
- D. Capillary refill time.
Correct Answer: A
Rationale: Magnesium sulfate administration risks toxicity, especially in hypomagnesemia. Depressed deep tendon reflexes are an early sign of magnesium toxicity, requiring close monitoring. Arterial blood gases, skin turgor, and capillary refill are unrelated to magnesium therapy.
Which respiratory pattern is the best description of the client's breathing?
- A. Fast, deep, labored respirations
- B. Shallow respirations, alternating with apnea
- C. Slow inhalation and exhalation through pursed lips
- D. Shortness of breath with pauses
Correct Answer: A
Rationale: Kussmaul's respirations in DKA are fast, deep, and labored to compensate for metabolic acidosis.
The unlicensed assistive personnel (UAP) complains to the nurse she has filled the water pitcher four (4) times during the shift for a client diagnosed with a closed head injury and the client has asked for the pitcher to be filled again. Which intervention should the nurse implement first?
- A. Tell the UAP to fill the pitcher with ice cold water.
- B. Instruct the UAP to start measuring the client's I&O.
- C. Assess the client for polyuria and polydipsia.
- D. Check the client's BUN and creatinine levels.
Correct Answer: C
Rationale: Frequent water pitcher refills suggest polydipsia and polyuria, symptoms of diabetes insipidus post-head injury, requiring assessment. I&O, labs, and refilling follow.