◉ An adolescent who was diagnosed with diabetes mellitus Type 1
at the age of 9, is admitted to the hospital in diabetic ketoacidosis.
Which occurrence is the most likely cause of the ketoacidosis?
A. Ate an extra peanut butter sandwich before gym class
B. incorrectly administered too much insulin
C. Had a cold and ear infection for the past two days
D. Skipped eating lunch.
Answer: C. Had a cold and ear infection for the past two days
◉ A client with a prescription for "do not resuscitate" (DNR) begins
to manifest signs of impending death. After notifying the family of
the client's status, what priority action should the nurse implement?
A. The impending signs of death should be documented
B. The client's status should be conveyed to the chaplain
C. The client's need for pain medication should be determined
D. The nurse manager should be updated on the client's status.
Answer: C. The client's need for pain medication should be
determined
,◉ Which self care measure is most important for the nurse to
include in the plan of care of a client recently diagnosed with type 2
diabetes mellitus?
A. Self-injection techniques
B. Blood glucose monitoring
C. Diabetic diet meal planning
D. A realistic exercise plan.
Answer: B. Blood glucose monitoring
◉ A client who gave birth 48 hours ago has decided to bottle feed
the infant. During the assessment, the nurse observes that both
breasts are swollen, warm, and tender on palpation. Which
instruction should the nurse provide?
A. Apply ice to the breasts for comfort
B. Wear a loose-fitting bra during the day to prevent nipple irritation
C. Run warm water over breasts
D. Express small amounts of milk from the breasts to relieve
pressure.
Answer: A. Apply ice to the breasts for comfort
◉ The nurse is preparing a client who had a below-the-knee (BKA)
amputation for discharge to home. Which recommendations should
the nurse provide this client? (Select all that apply)
A. Avoid range of motion exercises
,B. Use a residual limb shrinker
C. Apply alcohol to the stump after bathing
D. Inspect skin for redness
E. Wash the stump with soap and water.
Answer: B. Use a residual limb shrinker
D. Inspect skin for redness
E. Wash the stump with soap and water
◉ A toddler presenting with a history of intermittent skin rashes,
hives, abdominal pain, and vomiting that occurs after ingesting of
milk products arrives to the clinic accompanied by the parents.
Which type of testing should the nurse provide education to the
toddler's family about?
A. Serum immunoglobulin E (IgE)
B. Intradermal test
C. Atopy patch test
D. Placebo-controlled food challenge.
Answer: A. Serum immunoglobulin E (IgE)
◉ A client who is scheduled for a bronchoscopy in the morning is
anxious and asking the nurse numerous questions about the
procedure. In preparing the client for the procedure, which
intervention has the highest priority?
A. Allow client to gargle with warm salt water
, B. Administer a sedative to alleviate anxiety
C. Instruct client to write down the questions
D. Deny client's request for a midnight snack.
Answer: C. Instruct client to write down the questions
◉ The nurse assesses a client one hour after starting a transfusion of
packed red blood cells and determines that there are no indications
of a transfusion reaction. What instruction should the nurse provide
the unlicensed assistive personnel (UAP) who is working with the
nurse?
A. Notify the nurse when the transfusion has finished, so further
client assessment can be done
B. Continue to measure the client's vital signs every thirty minutes
until the transfusion is complete
C. Monitor the client carefully for the next three hours and report the
onset of a reaction immediately
D. Since a reaction did not occur, the priority is to maintain client
comfort during the transfusion.
Answer: B. Continue to measure the client's vital signs every thirty
minutes until the transfusion is complete
◉ The healthcare provider prescribes a sepsis protocol for a client
with multi-organ failure caused by a ruptured appendix. Which
intervention is most important for the nurse to include in the plan of
care?