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1. A nurse is caring for an infant who is receiving IV fluids for dehydration. Which of the following should the nurse recognize as a positive response to the therapy?
- A. Tachycardia
- B. Hypotension
- C. Increased urine output
- D. Diarrhea
Correct answer: C
Rationale: Increased urine output is a positive sign that the IV fluids are effectively treating dehydration. Tachycardia (choice A) and hypotension (choice B) are signs of dehydration and would not be considered positive responses to therapy. Diarrhea (choice D) can worsen dehydration and is not a positive response to IV fluid therapy.
2. What are the primary differences between Type 1 and Type 2 diabetes in terms of pathophysiology and treatment?
- A. Type 1: No insulin production; Type 2: Insulin resistance
- B. Type 1: Insulin resistance; Type 2: Insulin deficiency
- C. Type 1: Autoimmune; Type 2: Lifestyle-related
- D. Type 1: Insulin therapy; Type 2: Diet modification
Correct answer: A
Rationale: The correct answer is A. Type 1 diabetes is characterized by the absence of insulin production, while Type 2 diabetes involves insulin resistance. Choice B is incorrect because Type 1 diabetes is not related to insulin resistance. Choice C is inaccurate as Type 1 diabetes is autoimmune while Type 2 diabetes is more associated with lifestyle factors. Choice D is not correct since insulin therapy is primarily used in Type 1 diabetes, whereas diet modification is a common approach in managing Type 2 diabetes.
3. A client is learning to use a cane due to left-leg weakness. Which instruction is correct?
- A. Use the cane on the stronger side of the body
- B. Maintain two points of support on the floor at all times
- C. Advance the cane and the strong leg together
- D. Advance the cane 30 to 45 cm with each step
Correct answer: B
Rationale: The correct instruction when using a cane due to leg weakness is to maintain two points of support on the floor at all times. This provides stability and support while walking. Choice A is incorrect because the cane should be used on the weaker side to provide assistance. Choice C is incorrect as the cane and weak leg should move together for support. Choice D is incorrect as advancing the cane too far with each step may compromise balance and stability.
4. A nurse is caring for a client who is postoperative following a thyroidectomy and reports tingling and numbness in the hands. The nurse should expect to administer which of the following medications?
- A. Sodium bicarbonate.
- B. Calcium gluconate.
- C. Potassium chloride.
- D. Magnesium sulfate.
Correct answer: B
Rationale: Tingling and numbness in the hands can indicate hypocalcemia, a common complication following a thyroidectomy. Hypocalcemia requires immediate intervention to prevent severe complications like tetany and seizures. Calcium gluconate is the drug of choice for rapidly raising serum calcium levels in hypocalcemic patients. Sodium bicarbonate is not indicated for treating hypocalcemia or related symptoms. Potassium chloride is used to correct potassium imbalances, not calcium. Magnesium sulfate is not the appropriate treatment for hypocalcemia; it is commonly used for conditions like preeclampsia or eclampsia.
5. Which nursing intervention is essential for a client diagnosed with heart failure?
- A. Encourage fluid intake to prevent dehydration
- B. Monitor the client's weight daily to assess fluid balance
- C. Increase sodium intake to prevent fluid retention
- D. Limit fluid intake to avoid overload
Correct answer: B
Rationale: The correct answer is to monitor the client's weight daily to assess fluid balance in clients with heart failure. This intervention helps healthcare providers evaluate fluid retention or loss, which is crucial in managing heart failure. Choice A is incorrect because excessive fluid intake can worsen heart failure symptoms by causing fluid overload. Choice C is incorrect because increasing sodium intake can lead to fluid retention, exacerbating heart failure. Choice D is incorrect as limiting fluid intake excessively can also be harmful in heart failure management, potentially leading to dehydration.
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