Nokea
Which of the following statements about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS)?
- A. Administer 2 to 3L of IV fluid rapidly
- B. Administer 6L of IV fluid over the first 24 hours
- C. Administer a dextrose solution containing normal saline solution
- D. Administer IV fluid slowly to prevent circulatory overload and collapse
Correct Answer: B
Rationale: The correct answer is B: Administer 6L of IV fluid over the first 24 hours. In HHNS, dehydration is severe due to high blood glucose levels causing osmotic diuresis. Rapid infusion of fluid can lead to fluid overload and exacerbate the situation. Administering 6L over 24 hours helps gradually replenish lost fluids without causing circulatory overload. Choice A is incorrect because rapid infusion can lead to fluid overload. Choice C is incorrect because adding dextrose to the solution can further increase blood glucose levels. Choice D is incorrect because administering IV fluids slowly can delay rehydration in a critical situation like HHNS.
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When taking the blood pressure of a client who has AIDS the nurse must;
- A. Wear a mask and gown
- B. Use barrier techniques
- C. Wash the hands thoroughly
Correct Answer: B
Rationale: The correct answer is B: Use barrier techniques. When taking the blood pressure of a client with AIDS, using barrier techniques such as gloves and disposable equipment is crucial to prevent the transmission of the virus through blood or bodily fluids. Wearing a mask and gown (choice A) may not be necessary unless there is a risk of splashes or sprays. Washing hands thoroughly (choice C) is important, but alone may not provide sufficient protection. Choice D is incomplete.
Which of the following client outcomes best describes the parameters for achieving the outcome?
- A. The client will eat a well-balanced diet.
- B. The client will consume a 2,400-calorie diet, with three meals and two snacks, starting tomorrow.
- C. The client will cleanse his wound with soap and water and apply a dry sterile dressing.
- D. The client will be without pain in 24 hours.
Correct Answer: B
Rationale: The correct answer is B because it provides specific, measurable, achievable, relevant, and time-bound (SMART) parameters for achieving the outcome. It outlines the calorie intake, meal frequency, and start date, which allows for clear monitoring and evaluation of progress. Choice A is too vague and lacks specificity. Choice C focuses on wound care, not dietary goals. Choice D lacks specificity and a timeframe, making it difficult to measure success. In conclusion, choice B is the best option as it aligns with effective goal-setting principles.
A 61-year old female patient with diabetes is in the emergency department after stepping on a sharp onject while walking barefoot on the beach. The patient did not notice that the object pierced the skin unitl later that evening. What problem does she probably have?
- A. neuropathy on her peripheral
- B. nephropathy
- C. carpal tunnel syndrome
- D. macroangiopathy
Correct Answer: A
Rationale: The correct answer is A: neuropathy on her peripheral. In diabetes, peripheral neuropathy is common, causing loss of sensation in the feet, making it difficult to feel injuries like stepping on a sharp object. This can lead to delayed detection of wounds, increasing the risk of infections and complications. Nephropathy (B) refers to kidney damage, carpal tunnel syndrome (C) involves compression of the median nerve in the wrist, and macroangiopathy (D) refers to large blood vessel disease, which are not directly related to the scenario described.
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
- A. “Avoid drinking liquids until the gag reflex returns.”
- B. “Avoid eating milk products for 24 hours.”
- C. “Notify a nurse if you experience blood in your urine.”
- D. “Remain supine for the time specified by the physician.”
Correct Answer: D
Rationale: The correct answer is D: “Remain supine for the time specified by the physician.” After a subarachnoid block, the client must remain lying down to prevent complications like spinal headaches due to cerebrospinal fluid leakage. This position helps maintain adequate spinal fluid pressure. Choice A is incorrect as fluid intake is important postoperatively. Choice B is not relevant to a subarachnoid block. Choice C is important but not the most crucial instruction compared to maintaining the supine position.
The nurse is teaching the client about risk factors for diabetes mellitus. Which of the following risk factors for diabetes mellitus is nonmodifiable?
- A. Poor control of blood glucose levels
- B. Current of recent foot trauma
- C. Inappropriate foot care
- D. Advanced age
Correct Answer: D
Rationale: Step 1: Define nonmodifiable risk factors - these are factors that cannot be changed or controlled by the individual.
Step 2: Advanced age is a nonmodifiable risk factor as it is determined by genetics and time.
Step 3: Poor control of blood glucose levels, foot trauma, and inappropriate foot care are modifiable risk factors that can be managed through lifestyle changes or medical interventions.
Summary: Choice D is correct because advanced age is a nonmodifiable risk factor for diabetes mellitus, while the other choices involve factors that can be modified through appropriate actions.