Nokea
A client with newly diagnosed diabetes mellitus.
Which of the following statements, if made by the client to the nurse, would indicate that further teaching is necessary?
- A. I should cut my toenails straight across.
- B. I should not go barefoot.
- C. I should inspect my feet once a week.
- D. I should bathe my feet daily in warm water.
Correct Answer: C
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents ingrown nails (2) prevents possible injury to feet (3) correct-should inspect feet daily for blisters, sores, ingrown nails, and cuts (4) proper care
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The nurse is caring for a client with a history of Cushing’s syndrome.
- A. Which symptom is expected in a client with Cushing’s syndrome?
- B. Weight loss and fatigue.
- C. Moon face and truncal obesity.
- D. Hypotension and bradycardia.
- E. Polyuria and thirst.
Correct Answer: B
Rationale: Moon face and truncal obesity result from cortisol excess in Cushing’s syndrome. Weight loss, hypotension, and polyuria are more typical of Addison’s disease or diabetes insipidus.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings would be of GREATest concern to the nurse?
- A. Calcium level of 8.0 mg/dL.
- B. Temperature of 99.5°F (37.5°C).
- C. Heart rate of 100 bpm.
- D. Pain at the incision site.
Correct Answer: A
Rationale: A calcium level of 8.0 mg/dL indicates hypocalcemia, a serious complication post-thyroidectomy due to parathyroid damage, risking tetany or seizures. Options B, C, and D are expected: slight fever, tachycardia, and incision pain are common postoperatively.
A client has a Swan-Ganz catheter in place. The nurse understands that this is intended to measure
- A. right heart function
- B. left heart function
- C. renal tubule function
- D. carotid artery function
Correct Answer: B
Rationale: left heart function. The Swan-Ganz catheter is placed in the pulmonary artery to obtain information about the left side of the heart. It can provide hemodynamic information such as intracardiac pressure readings and oxygen saturation data, and even transvenous pacing. Information about left ventricular function is important because it directly affects tissue perfusion. Right-sided heart function is assessed through the evaluation of the central venous pressure (CVP).
A 69-year-old man is receiving dexamethasone (Decadron) 3 mg PO TID for chronic lymphocytic leukemia. It is MOST important for the nurse to report which of the following findings to the physician?
- A. PT 12 seconds and Hgb 15 g/dL.
- B. BUN 18 mg/dL and creatinine 1.0 mg/dL.
- C. K⺠3.4 mEq/L and CA⺠5/5 mEq/L.
- D. AST (SGOT) 18 U/L and ALT (SGPT) 12 U/L.
Correct Answer: C
Rationale: normal Kâ 3.5-5.0 mEq/L, normal Ca 4.5-5.3 mEq/L, indicates hypokalemia and hypercalcemia
A nurse who travels with an agency is uncertain about what tasks can be performed when working in a different state. It would be best for the nurse to check which resource?
- A. The state nurse practice act in which the assignment is made
- B. With a nurse colleague who has worked in that state 2 years ago
- C. The policies and procedures of the assigned agency in the state
- D. The Nursing Social Policy Statement within the United States
Correct Answer: A
Rationale: The state nurse practice act is the governing document of the scope of practice in the given state.