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A nurse is assessing a client who has type one diabetes myelitis and was administered insulin lispro 1 hour ago.
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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A nurse in a long-term care facility is admitting a client with dementia.
Which of the following actions should the nurse take to reduce the risk for client injury?
- A. Keep the television on during the night
- B. Place the bedside table at the foot of the bed
- C. Raise the side rails up when the client is in bed
- D. Assist the client to the toilet frequently
Correct Answer: C
Rationale: The correct answer is C: Raise the side rails up when the client is in bed. This action helps prevent falls and injuries by providing a physical barrier to keep the client from rolling out of bed. Keeping the television on (choice A) does not directly address client safety. Placing the bedside table at the foot of the bed (choice B) may not prevent falls or injuries. Assisting the client to the toilet frequently (choice D) is important for personal care but does not directly reduce the risk for client injury.
A nurse is caring for a 9-year-old child at a clinic.
Nurses' Notes
1000:
Child has been brought to the clinic by their parent due to a report of right arm pain. The parent
states that several hours ago the child tripped and fell onto the sidewalk while playing
outside. The child states, "I was running when we were playing. and I tripped over a curb." Child
is supporting their arm across their body.
Assessment
Respirations easy and unlabored, Abdomen non-distended. Right forearm and fingers are
edematous. Ecchymotic area noted on outer aspect of the forearm. Radial pulse +2. Fingers
slightly cool to touch. Child can move fingers and reports a mild "tingling" sensation, Child
verbalizes a pain level of 4 on a scale of 0 to 10, Multiple areas of bruising are noted on lower
extremities in various stages of healing
Vital. Signs
Temperature 36.8°C (98.2° F)
Heart rate 102/min
Respiratory rate 22/min
BP 100/60 mm Hg
Oxygen saturation 98% on room air
Nurse reviews the assessment findings. Which findings require immediate follow-up?
- A. Right forearm and fingers are edematous.
- B. Ecchymotic area noted on outer aspect of the forearm.
- C. Heart rate 102/min
- D. Fingers slightly cool to touch.
- E. Child verbalizes a pain level of 4 on a scale of 0 to 10
- F. Respiratory rate 22/min
Correct Answer: A,D
Rationale: Edema and coolness in the extremity suggest circulatory impairment, warranting immediate attention.
A nurse is planning teaching for a client who has a newly implanted implantable cardioverter/defibrillator.
Which of the following information should the nurse include?
- A. Return in two weeks for a follow up MRI - MRI should be avoided
- B. Expect to have a rapid pulse rate for the first few weeks?
- C. Resume tub baths and swimming after 24hr
- D. Wear loose fitting clothing
Correct Answer: D
Rationale: The correct answer, D, "Wear loose fitting clothing," is important post-surgery to prevent constriction on the surgical site and promote healing. Tight clothing can lead to increased pain and delayed recovery. Choice A is incorrect as MRI should be avoided post-surgery due to potential interference with healing. Choice B is incorrect as a rapid pulse rate is not a typical expectation post-surgery. Choice C is incorrect as tub baths and swimming should be avoided to prevent infection.
A charge nurse is teaching a new staff member about factors that increase a client's risk to become violent.
Which risk factor should the nurse include as the best predictor of future violence?
- A. Previous violent behavior
- B. Low self-esteem
- C. Substance use disorder
- D. A history of depression
Correct Answer: A
Rationale: The correct answer is A: Previous violent behavior. This is the best predictor of future violence because past behavior is a strong indicator of future actions. Individuals who have a history of violent behavior are more likely to exhibit violent tendencies again. Low self-esteem (B), substance use disorder (C), and a history of depression (D) can contribute to increased risk of violence, but they are not as reliable predictors as previous violent behavior. A history of violence is a key factor in assessing the potential for future violent acts.
A nurse is reporting a client's laboratory test to the provider to obtain a prescription for warfarin.
Which laboratory test should the nurse report?
- A. INR
- B. Prothrombin time (PT)
- C. Activated partial thromboplastin time (aPTT)
- D. Platelet count
- E. Hemoglobin and hematocrit levels
Correct Answer: A
Rationale: The correct answer is A: INR. The nurse should report the INR (International Normalized Ratio) test because it specifically measures the effectiveness of anticoagulant therapy like warfarin. A high INR indicates a higher risk of bleeding, while a low INR indicates a higher risk of clotting. Reporting the INR can help healthcare providers adjust medication dosage to maintain optimal therapeutic levels.
Incorrect choices:
B: Prothrombin time (PT) is related to INR but is less specific for monitoring anticoagulant therapy.
C: Activated partial thromboplastin time (aPTT) is used to monitor heparin therapy, not warfarin.
D: Platelet count assesses the number of platelets, not the effectiveness of anticoagulant therapy.
E: Hemoglobin and hematocrit levels assess blood volume and oxygen-carrying capacity, not anticoagulant therapy.