Nokea
Which of the following indicates a potential complication of diabetes mellitus?
- A. Inflamed, painful joints.
- B. Blood pressure of 160/100 mm Hg.
- C. Hemoglobin of 11 g/dL.
- D. Fasting blood glucose of 90 mg/dL.
Correct Answer: B
Rationale: Hypertension (160/100 mm Hg) is a common complication of diabetes, contributing to cardiovascular and kidney disease.
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A client has been admitted with draining foot lesions. The nurse should do which of the following? Select all that apply.
- A. Place the client in a room with negative air pressure.
- B. Admit the client to a semi-private room.
- C. Admit the client to a private room.
- D. Post a "contact isolation" sign on the door.
- E. Wear a protective gown when in the client's room.
- F. Wear latex-free gloves when providing direct care.
Correct Answer: C,D,E,F
Rationale: Draining lesions require contact precautions, including a private room, isolation signage, gowns, and gloves (latex-free to avoid allergies). Negative pressure is for airborne pathogens.
A hospice client's family asks how they will know when death is imminent. The nurse should explain that signs include:
- A. Increased energy and mobility.
- B. Cheyne-Stokes respirations.
- C. Improved blood pressure.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Cheyne-Stokes respirations, characterized by alternating periods of apnea and deep breathing, are a common sign of imminent death.
A client is having a blood transfusion reaction. The nurse must do the following in what order of priority from first to last?
- A. Notify the attending physician and blood bank.
- B. Complete the appropriate Transfusion Reaction Form(s).
- C. Stop the transfusion.
- D. Keep the I.V. open with normal saline infusion.
Correct Answer: C,D,A,B
Rationale: In a transfusion reaction, the nurse must first stop the transfusion to prevent further infusion of the offending blood. Next, keep the IV line open with normal saline to maintain access and support circulation. Then, notify the physician and blood bank for further evaluation and management. Finally, complete the transfusion reaction forms to document the incident.
The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.
The nurse is preparing to administer ten units of regular insulin and twenty units of NPH insulin. Which of the following actions is correct when mixing the insulins?
- A. Aspirate insulin from the NPH vial first.
- B. Roll the regular insulin vial prior to aspirating insulin.
- C. Aspirate the regular insulin first before NPH.
- D. Instill air into the regular insulin vial first.
Correct Answer: C
Rationale: Regular insulin is drawn up first to prevent contamination of the clear insulin with the cloudy NPH.