Nursing Elites

1. During a physical assessment of a client with type 2 DM, a nurse notes the following findings: fasting blood glucose of 120 mg/dl, temperature of 101°F, pulse 88 bpm, respirations 22/min, and BP 140/84 mmHg. Which finding should concern the nurse the most?

• A. Pulse
• B. BP
• C. Respiration
• D. Temperature

Correct answer: D

Rationale: The correct answer is 'Temperature.' A temperature of 101°F indicates a fever, which can be a sign of infection. In individuals with diabetes, infections can lead to significant complications and affect blood glucose control. Monitoring and addressing infections promptly are crucial in individuals with diabetes to prevent worsening of their condition. Choice A, 'Pulse,' is within the normal range (60-100 bpm) and does not indicate an immediate concern. Choice B, 'BP,' while slightly elevated, is not as acutely concerning as an elevated temperature in this scenario. Choice C, 'Respiration,' falls within the normal range (12-20 breaths/min) and is not the most concerning finding among the options provided.

2. The nurse is caring for a client with hyperparathyroidism. Which of the following clinical manifestations is consistent with this condition?

• A. Hypocalcemia
• B. Hypercalcemia
• C. Hypokalemia
• D. Hyperphosphatemia

Correct answer: B

Rationale: In hyperparathyroidism, there is an overproduction of parathyroid hormone, leading to increased calcium levels in the blood (hypercalcemia). This occurs as the parathyroid hormone stimulates the release of calcium from the bones and enhances calcium absorption in the intestines and kidneys. Therefore, the correct answer is hypercalcemia (Choice B). Hypocalcemia (Choice A) is not consistent with hyperparathyroidism, as this condition is characterized by high calcium levels. Hypokalemia (Choice C) and hyperphosphatemia (Choice D) are not typically associated with hyperparathyroidism and are not primary manifestations of this condition.

3. A female adult client with a history of chronic hyperparathyroidism admits to being noncompliant. Based on initial assessment findings, the nurse formulates the nursing diagnosis of Risk for injury. To complete the nursing diagnosis statement for this client, which 'related-to' phrase should the nurse add?

• A. Related to bone demineralization resulting in pathologic fractures
• B. Related to exhaustion secondary to an accelerated metabolic rate
• C. Related to edema and dry skin secondary to fluid infiltration into the interstitial spaces
• D. Related to tetany secondary to a decreased serum calcium level

Correct answer: A

Rationale: The correct answer is A: 'Related to bone demineralization resulting in pathologic fractures.' In chronic hyperparathyroidism, bone demineralization occurs due to the excessive release of parathyroid hormone, leading to increased calcium resorption from bones. This process weakens the bones, making the client prone to pathologic fractures. Choices B, C, and D are incorrect because they do not directly relate to the increased risk of injury associated with chronic hyperparathyroidism. Exhaustion, edema, dry skin, and tetany are not the primary risks for injury in this client population.

4. A client with DM is experiencing symptoms of hypoglycemia. Which action should the nurse take first?

• A. Give the client a glass of orange juice.
• B. Administer insulin as ordered.
• C. Check the client's blood glucose level.
• D. Notify the healthcare provider.

Correct answer: C

Rationale: The correct first action when a client with DM is experiencing symptoms of hypoglycemia is to check the client's blood glucose level. This step is crucial to confirm hypoglycemia before initiating any treatment. Giving the client orange juice (Choice A) is a common intervention for treating hypoglycemia, but it should not be done before confirming the blood glucose level. Administering insulin (Choice B) is not appropriate for hypoglycemia as it would further decrease the blood glucose levels. Notifying the healthcare provider (Choice D) can be important, but the immediate priority is to assess the blood glucose level to guide treatment.

5. A nurse is preparing to administer insulin to a client with DM. The nurse understands that the peak time for rapid-acting insulin, such as lispro (Humalog), is:

• A. 30 minutes to 1 hour after administration.
• B. 1 to 2 hours after administration.
• C. 2 to 4 hours after administration.
• D. 3 to 5 hours after administration.

Correct answer: A

Rationale: The correct answer is A: 30 minutes to 1 hour after administration. Rapid-acting insulins like lispro, such as Humalog, peak quickly within 30 minutes to 1 hour after administration. This peak time is crucial to monitor for potential hypoglycemia, which is most likely to occur during this period. Choice B is incorrect as it suggests a longer peak time for rapid-acting insulin, which is inaccurate. Choices C and D are also incorrect because they indicate even longer peak times, which do not align with the rapid onset and peak action of lispro insulin.

Similar Questions