UPDATED EXAM ACTUAL LATEST VERSIONS 50
QUESTIONS AND CORRECT VERIFIED
ANSWERS WITH RATIONALES (100%
CORRECT) A+ GRADED ASSURED
A client diagnosed with insulin-dependent diabetes mellitus tells the nurse, "I am having a
hypoglycemic reaction." What should the nurse select to treat this problem?
A. 4 oz of orange juice
B. half a cup of sugar free soda
C. 25 jelly beans
D. 1 teaspoon of honey CORRECT ANSWER: A. 4 oz of orange juice
Rationale: A 10-15g simple carbohydrate load is generally needed to increase the blood glucose
level quickly and adequately
A client newly diagnosed with type 1 diabetes mellitus exercises daily. When teaching this client
about medication therapy, the nurse tells the client to inject the daily dose of insulin in which
location?
A. In a site that will be exercised
B. In a site that will not be exercised
C. In a site that is intermittently exercised CORRECT ANSWER: B. In a site that will not be
exercised
,Rationale: Exercise of a body part increases the rate of absorption of insulin from that site. For
this reason, the client should inject insulin into an area that will not be exercised. This will help
the client to avoid hypoglycemia from rapid insulin absorption.
A nurse is assessing a client who has a fluid overload. Which of the following findings should
the nurse expect? (Select all that apply).
A. increased heart rate
B. increased blood pressure
C. increased respiratory rate
D. increased hematocrit
E. increased temperature CORRECT ANSWER: A. increased heart rate
B. increased blood pressure
C. increased respiratory rate
Rationale: An increased hematocrit and temperature are indicative of a fluid volume deficit not a
fluid volume overload
A nurse is assessing a client who has a sodium level of 116mEq/L. Which of the following
findings should the nurse expect?
A. nausea and vomiting
B. Extreme thirst
C. Flushed skin CORRECT ANSWER: A. nausea and vomiting
Rationale: A sodium value of 116mEq/L indicates hyponatremia. Nausea and vomiting are
expected findings for a client with this sodium level.
, A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea.
Which of the following findings should the nurse expect?
A. hyperactive reflexes
B. extreme thirst
C. weak, irregular pulse CORRECT ANSWER: C. weak, irregular pulse
Rationale: Common manifestations of potassium depletion include a weak and irregular pulse,
muscle weakness, fatigue, and ventricular dysrhythmias
A nurse is assessing an older adult client who is receiving IV therapy. The nurse should
recognize that which of the following findings indicates fluid volume excess? (Select all that
apply).
A. bounding pulse
B. pitting edema
C. swelling at IV site
D. urine specific gravity greater than 1.030
E. crackles upon auscultation CORRECT ANSWER: A. bounding pulse
B. pitting edema
E. crackles upon auscultation
Rationale:
Swelling at IV site indicates fluid accumulation due to infiltration not due to fluid volume
excess. Urine specific gravity measures concentration of all chemical particles in urine. A urine
specific gravity greater than 1.030 indicates dehydration while a gravity less than 1.010 indicates
fluid volume excess
A nurse is caring for a client who has a blood glucose of 52mg/dL. The client is lethargic but
arousable. Which of the following actions should the nurse perform first?