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Which respiratory pattern is the best description of the client's breathing?
- A. Fast, deep, labored respirations
- B. Shallow respirations, alternating with apnea
- C. Slow inhalation and exhalation through pursed lips
- D. Shortness of breath with pauses
Correct Answer: A
Rationale: Kussmaul's respirations in DKA are fast, deep, and labored to compensate for metabolic acidosis.
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The charge nurse of an intensive care unit is making assignments for the night shift. Which client should be assigned to the most experienced intensive care nurse?
- A. The client diagnosed with respiratory failure who is on a ventilator and requires frequent sedation.
- B. The client diagnosed with lung cancer and iatrogenic Cushing's disease with ABGs of pH 7.35, PaO2 88, PaCO2 44, and HCO3 22.
- C. The client diagnosed with Addison's disease who is lethargic and has a BP of 80/45, P 124, and R 28.
- D. The client diagnosed with hyperthyroidism who has undergone a thyroidectomy two (2) days ago and has a negative Trousseau's sign.
Correct Answer: C
Rationale: Addison’s with hypotension (80/45), tachycardia (124), and lethargy suggests adrenal crisis, requiring an experienced nurse. Ventilator care, stable Cushing’s, and post-thyroidectomy are less acute.
Which intervention is most appropriate to add to the client's care plan to the use of the personal bleeding after a subtotal thyroidectomy?
- A. Observe for signs of hypovolemic shock.
- B. Assess for dampness at the back of the client's neck.
- C. Remove the dressing to directly inspect the wound.
- D. Weigh all gauze dressings before and after changing.
Correct Answer: B
Rationale: Assessing for dampness at the back of the neck detects bleeding that may pool behind the client.
Using the Dietary Exchange Plan for a 1,500 calorie diet in the chart below, which item is appropriate for the diabetic client to have in the midafternoon?
- A. An 8-oz carton of milk
- B. Two stream careers
- C. A medium apple
- D. A 2-oz slice of turkey
Correct Answer: C
Rationale: The midafternoon snack in the exchange plan includes one fruit serving, making a medium apple appropriate.
Which instruction by the nurse concerning the test procedure is most accurate?
- A. You need to eat a large meal just before the test.
- B. You can drink coffee or tea in the morning before the test.
- C. You will be given a sweetened drink before the test.
Correct Answer: C
Rationale: A glucose tolerance test involves administering a sweetened drink to assess the body's response to glucose.
The client residing in a long-term care facility has type 2 DM and is sick with the stomach flu. The client's blood glucose is 245 mg/dL. Which action should the nurse take next?
- A. Have the client void and check the urine for ketones.
- B. Keep the client NPO until blood glucose levels decline.
- C. Immediately contact the client's health care provider.
- D. Continue to monitor blood glucose levels every 6 hours.
Correct Answer: A
Rationale: The nurse should check the client's urine for ketones whenever the blood glucose level is greater than 240 mg/dL.