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Which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide (DiaBeta)?
- A. Administer glyburide again
- B. Administer subcutaneous insulin and monitor blood glucose
- C. Monitor blood glucose closely, and look for signs of hypoglycemia
- D. Monitor blood glucose and assess for signs of hyperglycemia
Correct Answer: C
Rationale: After a client complains of nausea and vomits one hour after taking glyburide, the priority nursing intervention should be to monitor blood glucose closely and look for signs of hypoglycemia. Vomiting could indicate that the glyburide was not properly absorbed, potentially leading to hypoglycemia. Administering glyburide again (Choice A) could worsen hypoglycemia. Administering subcutaneous insulin (Choice B) is not appropriate without assessing the blood glucose first. Monitoring for signs of hyperglycemia (Choice D) is not the immediate concern in this situation.
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A nurse in the emergency department is performing triage for a group of clients who were in a train crash. Which of the following clients should the nurse tag as emergent?
- A. A client who has an open fracture of the femur
- B. A client who has periorbital ecchymosis
- C. A client who has asymmetrical thorax
- D. A client who has a deep-partial thickness burn on the lower extremities
Correct Answer: C
Rationale: In a triage situation, an asymmetrical thorax suggests a potentially life-threatening condition such as a pneumothorax or hemothorax, requiring immediate attention. This client should be tagged as emergent. Periorbital ecchymosis and deep-partial thickness burns, while concerning, may not indicate an immediate life-threatening situation. An open fracture of the femur, although serious, can be prioritized after addressing emergent cases.
A case manager is preparing a discharge plan for a client following coronary artery bypass grafting surgery. Which of the following client issues should the nurse address first?
- A. Inadequate food supply
- B. Low pain tolerance
- C. Limited social support
- D. Decreased self-esteem
Correct Answer: A
Rationale: The nurse should address the inadequate food supply first as it directly impacts the client's health post-discharge. Proper nutrition is crucial for recovery after surgery, especially such as coronary artery bypass grafting. While low pain tolerance, limited social support, and decreased self-esteem are all important issues to address, addressing the client's nutritional needs is the priority in this scenario to ensure optimal recovery and healing.
Select a myth or falsehood relating to pain, pain management, and addiction.
- A. Addiction can be accurately predicted.
- B. Withdrawal, drug tolerance, and physical dependence do not indicate addiction.
- C. Pain medications should be avoided in patients with a substance abuse history.
- D. Addiction is signaled by deception and stockpiling by the client.
Correct Answer: A
Rationale: The correct answer is A because addiction cannot be accurately predicted. Choices B and C are incorrect. Withdrawal, drug tolerance, and physical dependence are not definitive signs of addiction, and pain medications can be used with patients who have a substance abuse history under careful monitoring. Choice D is incorrect because addiction is not solely signaled by deception and stockpiling; it is a complex condition with various behavioral, physical, and psychological aspects.
Which patient is exercising their right to autonomy in the context of patient rights?
- A. An 86-year-old female who remains independent in terms of the activities of daily living.
- B. An unemancipated 16-year-old who chooses to not have an intravenous line.
- C. A 32-year-old who does not need the help of the nurse to bathe and groom themselves.
- D. A 99-year-old who wants CPR despite the fact that the nurse and doctor do not think that it would be successful.
Correct Answer: D
Rationale: The correct answer is D. A 99-year-old exercising their right to autonomy in the context of patient rights by choosing CPR. Autonomy in healthcare refers to the patient's right to make their own decisions about their care, even if healthcare providers may disagree. In this scenario, the 99-year-old patient is exercising autonomy by making an informed choice about their medical treatment, despite healthcare professionals having a different opinion. Choices A, B, and C do not directly demonstrate the exercise of autonomy in decision-making regarding medical treatment, making them incorrect.
Insulin forces which of the following electrolytes out of the plasma and into the cells?
- A. Calcium
- B. Magnesium
- C. Phosphorus
- D. Potassium
Correct Answer: D
Rationale: Insulin forces potassium out of the plasma and into the cells, which can cause hypokalemia. This is because insulin enhances the activity of the sodium-potassium pump in cell membranes, promoting the movement of potassium from the extracellular fluid into the cells. Choices A, B, and C are incorrect as insulin does not directly influence the movement of calcium, magnesium, or phosphorus in the same manner as it does with potassium.