CORRECT/ACCURATE ANSWERS
The nurse assumes care of a postoperative adult client with type
2 diabetes mellitus and learns that the client has a current blood
glucose level of 720 mg/dL. When assessing the client, what is the
priority?
A. Assess for signs of fluid volume deficit
B. Observe wound drainage characteristics
C. Measure the level of acute pain
D. Determine when the client last ate - CORRECT ANSWERS- A.
Assess for signs of fluid volume deficit
An adult woman who was recently diagnosed with type 2 DM is
seen in the clinic for laboratory tests. The client's height is 5 feet
2 inches and weight is 165 pounds. Her recent laboratory findings
are described above. In planning nutrition teaching for this client,
what diet modifications should the nurse recommend?
Labs:
Creatinine 1.0 mg/dL
BUN 16 mg/dl
Diagnostics:
Total cholesterol 250 mg/dl
LDL 175 mg/dl
,HDL 35 mg/dl
Triglyceride 250 mg/dl
Flowsheets:
Glucose 150 mg/dl
A1c 9%
A. Decrease processed carbohydrate in diet
B. Eliminate alcohol intake except for special occasions
C. Restrict protein to 10% of total calories in diet
D. Increase dietary fiber such as whole grains
E. Reduce daily fat intake to 10% of total calories - CORRECT
ANSWERS- A. Decrease processed carbohydrate in diet
B. Eliminate alcohol intake except for special occasions
D. Increase dietary fiber such as whole grains
The nurse is caring for a client who is admitted to the emergency
center after a motor vehicle collision. The client begins to
experience a decreased level of consciousness and the pupils do
not respond equally to light. Which vital signs changes indicate
the client is manifesting Cushing's triad?
A. Blood pressure of 80/40 mmHg, weak heart rate of 40
beats/minute, Cheyne-Stokes respirations of 10 breaths/minute
B. Blood pressure 180/120 mmHg, weak heart rate of 92
beats/minute, Kussmaul respirations of 18 breaths/minute
,C. Blood pressure of 180/80 mmHg, bounding heart rate of 50
beats/minute, respirations of 30 breaths/minute with apneic
episodes
D. Blood pressure of 90/60 mmHg, strong heart rate of 60
beats/minute, eupneic respirations of 16 breaths/minute -
CORRECT ANSWERS- C. Blood pressure of 180/80 mmHg,
bounding heart rate of 50 beats/minute, respirations of 30
breaths/minute with apneic episodes
A young woman with multiple sclerosis just received several
immunizations in preparation for moving into a college dormitory.
Two days later, she reports to the nurse that she is experiencing
increasing fatigue and visual problems. What teaching should the
nurse provide?
A. Immunizations can trigger a relapse of the disease, so get
plenty of extra rest.
B. These early signs of an infection may require medical
treatment with antibiotics
C. These are common side effects of the vaccines and will resolve
in a few days
D. Plans to move into the dormitory need to be postponed for at
least a semester - CORRECT ANSWERS- A. Immunizations can
trigger a relapse of the disease, so get plenty of extra rest.
The nurse notices that a male client is particularly delusional one
afternoon. He begins to pace the floor and appears to be losing
control of himself. Which intervention is best for the nurse to
implement?
A. Move the client to a quiet place on the unti
, B. Encourage the client to use the punching bag
C. Use firmness and direct the client to sit for awhile
D. Suggest to the client that he take a walk - CORRECT ANSWERS-
A. Move the client to a quiet place on the unit
The practical nurse (PN) reports that a client who has a fingerstick
glucose of 35 mg/dL is alert and diaphoretic. What action should
the charge nurse take?
A. Assess client for polyuria and polyphagia
B. Give the client a glass of orange juice
C. Notify the healthcare provider
D. Collect a blood sample for hemoglobin A1c - CORRECT
ANSWERS- B. Give the client a glass of orange juice
While making rounds, the charge nurse notices that a young adult
client with asthma who was admitted yesterday is sitting on the
side of the bed and leaning over the bed-side table. The client is
currently receiving oxygen at 2 liters/minute via nasal cannula.
The client is wheezing and is using pursed-lip breathing. Which
intervention should the nurse implement?
A. Assist the client to lie back in bed
B. Administer a nebulizer treatment
C. Call for an Ambu resuscitation bag
D. Increase oxygen to 6 liters/minute - CORRECT ANSWERS- B.
Administer a nebulizer treatment