Nokea
Which laboratory test conducted on the client with diabetes mellitus indicates compliance?
- A. Fasting blood glucose
- B. Two-hour post-prandial
- C. Hgb A-1C
- D. Dextrostix
Correct Answer: C
Rationale: Hgb A-1C reflects average blood glucose over 2-3 months, indicating long-term compliance. Options A, B, and D provide short-term snapshots and are less reliable for compliance.
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The nurse is teaching a client with a new diagnosis of hyperthyroidism about methimazole (Tapazole). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any fever or sore throat.
- C. Stop the medication if thyroid levels normalize.
- D. Avoid regular thyroid function Test s.
Correct Answer: B
Rationale: Fever or sore throat may indicate agranulocytosis, a serious methimazole side effect. Options A, C, and D are incorrect.
A client whose father died from Huntington's chorea asks what the chances are that he will develop the disease. The nurse knows that the chances of the client developing the disease are:
- A. 25%
- B. 50%
- C. 100%
- D. 0%
Correct Answer: B
Rationale: Huntington's disease is autosomal dominant; with one affected parent, the client has a 50% chance of inheriting the gene and developing the disease.
The nurse is caring for clients on a psychiatric unit and is suddenly faced with multiple issues.
Which of the following situations require the nurse's IMMEDIATE attention?
- A. A client with bipolar disorder walks into the dayroom in her underwear and begins dancing.
- B. A client with depression says to the nurse, 'My plan is complete, and I'm ready to go for it.'
- C. A client recovering from substance abuse says to the nurse, 'My plan is complete, and I'm ready to go for it.'
- D. A client with schizophrenia tells the nurse that it's 'God's will' that he destroy the 'evil TV'.
Correct Answer: B
Rationale: Strategy: 'Require IMMEDIATE intervention' indicates that you are looking for the least stable situation. (1) should remove to quiet area, decrease environmental stimuli (2) correct-could indicate impending suicide, requires immediate follow-up (3) potential suicide is more immediate concern (4) command hallucination, potential suicide takes priority
The primary teaching for a client following an extracorporeal shock-wave lithotripsy (ESWL) procedure is
- A. Drink 3000 to 4000 cc of fluid each day for one month.'
- B. Limit fluid intake to 1000 cc each day for one month.'
- C. Increase fluid intake for the next three days.'
- D. Restrict milk and dairy products for one month.'
Correct Answer: A
Rationale: Drink 3000 to 4000 cc of fluid each day for one month.' Drinking three to four quarts (3000 to 4000 cc) of fluid each day will aid passage of fragments and help prevent formation of new calculi.
Which nursing action is MOST appropriate after intubating a postoperative client who had a respiratory arrest?
- A. Soak the intubation equipment in concentrated Betadine solution.
- B. Place the intubation blade in a bag and arrange for gas sterilization.
- C. Soak the intubation blade in Cidex solution.
- D. Wash the equipment with soap and water and allow to air-dry.
Correct Answer: B
Rationale: Gas sterilization ensures intubation equipment is pathogen-free, critical after exposure to body fluids. Options A, C, and D are inadequate for sterilization.