Nokea
Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus?
- A. Serum sodium.
- B. Serum calcium.
- C. Urine glucose.
- D. Urine white blood cells.
Correct Answer: A
Rationale: Diabetes insipidus causes dilute urine, risking hypernatremia; serum sodium monitoring is critical. Calcium, urine glucose, and WBCs are unrelated.
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The client diagnosed with Cushing's disease has developed 1++ peripheral edema. The client has received intravenous fluids at 100 mL/hr via IV pump for the past 79 hours. The client received intravenous piggyback (IVPB) medication in 50 mL of fluid every six (6) hours for 15 doses. How many mL of fluid did the client receive?
Correct Answer: 8650 mL
Rationale: Continuous IV: 100 mL/hr × 79 hr = 7900 mL. IVPB: 50 mL × 15 doses = 750 mL. Total = 7900 + 750 = 8650 mL.
Which action by the nurse provides the best data for monitoring the client's therapeutic response to sodium restriction?
- A. Monitoring sodium intake
- B. Measuring pedal edema
- C. Assessing skin turgor
- D. Weighing the client
Correct Answer: B
Rationale: Measuring pedal edema assesses fluid retention, a key indicator of sodium restriction response in Cushing's syndrome.
The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement?
- A. Ensure the client eats the bedtime snack.
- B. Determine how much food the client ate at lunch.
- C. Perform a glucometer reading at 0700.
- D. Offer the client protein after administering insulin.
Correct Answer: A
Rationale: Humulin N peaks in 4–12 hours, risking nocturnal hypoglycemia. A bedtime snack prevents this. Lunch intake is irrelevant, morning glucose checks are too late, and protein alone is insufficient.
During change of shifts, a nurse discovers that a hospitalized client with diabetes received two doses of insulin. After notifying the physician, which nursing action is most appropriate?
- A. Completing an incident report
- B. Calling the intensive care unit (ICU)
- C. Performing frequent neurologic checks
- D. Monitoring the client's blood glucose level
Correct Answer: D
Rationale: Monitoring blood glucose is critical to detect and manage potential hypoglycemia from the double dose.
An adolescent with IDDM is learning about a diabetic diet. He asks the nurse if he will ever be able to go out to eat with his friends again. What is the most appropriate answer for the nurse to give?
- A. You can go out with them, but you should take your own snack with you.'
- B. Yes. You will learn what foods are allowed so you can eat with your friends.'
- C. When you get food out in a restaurant, be sure to order diet soft drinks.'
- D. Eating out will not be possible on a diabetic diet. Why don't you plan to invite your friends to your house?'
Correct Answer: B
Rationale: Learning appropriate food choices allows the adolescent to eat out safely, promoting social integration and adherence to the diabetic diet.