Nokea
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
- A. Confusion
- B. Increased thirst
- C. Frequent urination
- D. Flushed skin
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is a condition characterized by low blood sugar levels, leading to symptoms like confusion due to the brain not receiving enough glucose for energy. Increased thirst and frequent urination are more indicative of hyperglycemia (high blood sugar levels). Flushed skin is not a common manifestation of hypoglycemia.
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Which of the following torts should the charge nurse identify as having occurred?
- A. Assault
- B. Battery
- C. False imprisonment
- D. Negligence
Correct Answer: A
Rationale: The charge nurse should identify assault as having occurred. Assault is the intentional act that causes a person to fear they will be harmed. In this case, if a healthcare provider threatens a patient with a procedure without their consent, it constitutes assault. Battery, on the other hand, is the intentional harmful or offensive touching of a person without consent. False imprisonment involves restraining a person against their will, which is not described in the scenario. Negligence refers to a failure to exercise reasonable care, and it does not apply here as the situation involves intentional actions.
A nurse is reviewing the client's electronic medical record. Which of the following findings require follow up?
- A. Potassium level
- B. Breath sounds
- C. WBC count
- D. Temperature
- E. Blood pressure
Correct Answer: C,D
Rationale: Decreased WBC count and elevated temperature suggest infection, requiring follow-up. Potassium levels remain within normal range, so no action is needed.
Which of the following actions should the nurse plan to take?
- A. Elevate the clients arm prior to insertion.
- B. Select a site on the client's dominant arm.
- C. Apply a tourniquet below the venipuncture site.
- D. Choose a vein that is palpable and straight.
Correct Answer: D
Rationale: The correct answer is D: Choose a vein that is palpable and straight. This is important because a palpable and straight vein ensures successful venipuncture and reduces the risk of complications such as infiltration or hematoma formation. Elevating the client's arm (A) may help visualize veins but does not guarantee choosing a suitable vein. Selecting a site on the client's dominant arm (B) is not necessary as both arms have suitable veins. Applying a tourniquet below the venipuncture site (C) can obstruct blood flow and distort the vein. Therefore, the best approach is to choose a vein that is palpable and straight for a successful venipuncture.
A nurse is providing teaching to a client who is 14 weeks of gestation about findings to report to the provider. Which of the following findings should the nurse include in the teaching?
- A. Bleeding gums
- B. Faintness upon rising
- C. Swelling of the face
- D. Urinary frequency
Correct Answer: C
Rationale: The correct answer is C: Swelling of the face. This finding could be indicative of preeclampsia, a serious condition in pregnancy characterized by high blood pressure and organ damage. It is crucial to report this to the provider promptly to prevent complications. Bleeding gums (A) are common due to hormonal changes and increased blood flow, not typically a cause for concern. Faintness upon rising (B) is common in pregnancy due to low blood pressure but usually not a significant issue unless severe. Urinary frequency (D) is normal in pregnancy due to the growing uterus pressing on the bladder.
Which statement should the nurse make?
- A. Bend at the waist when lifting objects from the floor.
- B. Keep the object close to your body when lifting.
- C. Twist your torso while lifting to maintain balance.
- D. Lift heavy objects quickly to reduce strain on the muscles.
Correct Answer: B
Rationale: The correct answer is B: Keep the object close to your body when lifting. This statement is correct because keeping the object close to the body reduces the strain on the back muscles and promotes proper lifting mechanics. By keeping the object close, the center of gravity is maintained, reducing the risk of injury.
Incorrect answers:
A: Bending at the waist when lifting can strain the lower back.
C: Twisting the torso while lifting can lead to back injuries.
D: Lifting heavy objects quickly can increase the risk of muscle strains and injuries.