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1. What are the complications of untreated Type 1 diabetes?
- A. Diabetic ketoacidosis and retinopathy
- B. Hypoglycemia and neuropathy
- C. Hypotension and kidney failure
- D. Infection and fluid overload
Correct answer: A
Rationale: Diabetic ketoacidosis and retinopathy are indeed common complications of untreated Type 1 diabetes. Diabetic ketoacidosis occurs when the body starts breaking down fat for fuel, leading to a dangerous buildup of ketones in the blood. Retinopathy refers to damage to the blood vessels of the retina due to high blood sugar levels over time. The other choices, hypoglycemia and neuropathy (choice B), hypotension and kidney failure (choice C), and infection and fluid overload (choice D) are not typically the primary complications associated with untreated Type 1 diabetes.
2. A nurse on a med surge unit has received change of shift report and will care for 4 clients. Which of the following clients' needs will the nurse assign to an AP?
- A. Feeding a client who was admitted 24 hours ago with aspiration pneumonia
- B. Reinforcing teaching with a client who is learning to walk with a quad cane
- C. Reapplying a condom catheter for a client who has urinary incontinence
- D. Applying a sterile dressing to a pressure ulcer
Correct answer: C
Rationale: The correct answer is C because reapplying a condom catheter for a client with urinary incontinence is a task that can be safely assigned to an assistive personnel (AP) as it falls within their scope of practice. Choice A involves the assessment of a client with aspiration pneumonia, which requires nursing judgment. Choice B requires teaching and guidance, which is the responsibility of the nurse. Choice D involves applying a sterile dressing, which requires nursing skills and knowledge.
3. A nurse is reinforcing home safety instructions with the parent of a newborn. Which of the following statements should the nurse include in the instructions?
- A. Place your baby's crib away from heat vents
- B. Place the crib close to a heater
- C. Place the crib near a window
- D. Place soft toys in the crib
Correct answer: A
Rationale: The correct answer is A: 'Place your baby's crib away from heat vents.' Placing the crib away from heat vents is essential to prevent the baby from becoming overheated and to reduce the risk of Sudden Infant Death Syndrome (SIDS). Choice B is incorrect because placing the crib close to a heater increases the risk of overheating and poses a fire hazard. Choice C is incorrect as placing the crib near a window exposes the baby to drafts and temperature fluctuations. Choice D is incorrect as soft toys in the crib can pose a suffocation risk to the newborn.
4. A nurse is collecting data from a client who delivered a full-term newborn 16 hr ago. The nurse notes excessive lochia discharge. Which of the following actions should the nurse take first?
- A. Administer oxytocin
- B. Perform fundal massage
- C. Administer IV fluids
- D. Call the provider
Correct answer: B
Rationale: Performing fundal massage is the priority action in this scenario. Fundal massage helps contract the uterus, which is essential in reducing excessive lochia postpartum. Administering oxytocin may be indicated later, but fundal massage should be the initial intervention to address the issue. Administering IV fluids may not directly address the cause of excessive lochia, and calling the provider should come after implementing immediate nursing interventions.
5. A client has developed phlebitis at the IV site. What should the nurse do first?
- A. Apply a warm compress to the IV site
- B. Discontinue the IV and notify the provider
- C. Monitor the IV site for signs of infection
- D. Administer an anti-inflammatory medication
Correct answer: B
Rationale: When a client develops phlebitis at the IV site, the priority action for the nurse is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and removing the IV can help prevent further complications. Applying a warm compress may provide symptomatic relief but does not address the root cause. Monitoring for infection is important, but immediate action to remove the source of inflammation is crucial. Administering an anti-inflammatory medication is not the first-line intervention for phlebitis; removal of the IV is necessary.
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