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1. The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask?
- A. "Are you anorexic?"
- B. "Is your urine dark colored?"
- C. "Have you lost weight lately?"
- D. "Do you crave sugary drinks?"
Correct answer: C
Rationale: Weight loss is a common symptom in the onset of type 1 diabetes due to the body's inability to use glucose for energy. The lack of insulin leads the body to break down fat and muscle for fuel, causing unintentional weight loss. This is a more relevant question compared to the others, as it directly relates to the metabolic changes associated with type 1 diabetes.
2. A nurse is evaluating teaching for a client who has heart failure. Which of the following statements by the client indicates an understanding of the teaching?
- A. I am limiting my sodium intake to 2 grams daily.
- B. I have been weighing myself every other morning.
- C. I am trying to decrease my intake of foods with potassium.
- D. I am eating fewer potato chips and more fruit for snacks.
Correct answer: A
Rationale: The correct answer is A. Limiting sodium intake is crucial for clients with heart failure to manage their condition effectively. Excessive sodium can lead to fluid retention and worsen heart failure symptoms. Weighing oneself is important for monitoring fluid retention but does not directly show an understanding of dietary restrictions. Decreasing potassium intake is not typically recommended for heart failure clients unless specifically advised by a healthcare provider. While choosing healthier snacks is beneficial, the focus on sodium intake is more critical for heart failure management.
3. A nurse has just inserted a nasogastric (NG) tube for a client. Which of the following findings should the nurse expect to confirm correct tube placement?
- A. The client reports relief of nausea.
- B. The tube aspirate has a pH less than 5.
- C. Bowel sounds are present on auscultation.
- D. An x-ray shows the end of the tube above the pylorus.
Correct answer: A
Rationale: The correct answer is A: The client reports relief of nausea. When the NG tube is correctly placed in the stomach, it can help alleviate feelings of nausea and discomfort. Choice B, a tube aspirate pH less than 5, is incorrect as it indicates gastric placement, not necessarily correct placement. Choice C, bowel sounds on auscultation, and Choice D, visualization of the tube on an x-ray above the pylorus, do not confirm correct NG tube placement; therefore, they are incorrect.
4. Which of the following is likely to facilitate union activity?
- A. Managers communicating effectively with employees
- B. Managers listening to concerns of employees
- C. Belief that low wages cause job dissatisfaction
- D. Belief that supervisors are not understanding of unionizing
Correct answer: C
Rationale: The correct answer is C because according to a study by Bilchik (2000), organizations are more likely to unionize if there is a belief that low wages cause job dissatisfaction. Choices A and B focus on effective communication and listening, which may actually prevent union activity by addressing employee concerns directly. Choice D, the belief that supervisors are not understanding of unionizing, may lead to dissatisfaction but doesn't directly facilitate union activity as the belief that low wages cause job dissatisfaction does.
5. A nurse is caring for a client who is postoperative. When the nurse prepares to change the client's dressing, they say, 'Every time you change my bandage, it hurts so much.' Which of the following interventions is the nurse's priority action?
- A. Encourage the client to relax and take deep breaths during the dressing change
- B. Educate the client about the importance of the dressing change to prevent infection
- C. Administer pain medication 45 minutes before changing the client's dressing
- D. Assist the client to a comfortable position for the dressing change
Correct answer: C
Rationale: The correct answer is to administer pain medication 45 minutes before changing the client's dressing. This intervention is the priority action because the client is experiencing pain during the dressing change. Providing pain relief beforehand can help minimize the discomfort and improve the overall experience for the client. Encouraging relaxation techniques (choice A) or educating about dressing change importance (choice B) are valuable but addressing pain is the priority. Assisting the client to a comfortable position (choice D) is essential for the procedure but does not directly address the client's pain.
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