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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. What is the priority for the nurse when caring for a patient with a chest tube?
- A. Ensure tube patency and observe for air leaks
- B. Maintain sterile technique during dressing changes
- C. Monitor drainage and record output
- D. Observe for signs of infection and monitor for subcutaneous emphysema
Correct answer: A
Rationale: The priority for the nurse when caring for a patient with a chest tube is to ensure tube patency and observe for air leaks. This is essential to prevent complications such as pneumothorax and ensure the patient's lung function. While maintaining sterile technique during dressing changes, monitoring drainage, recording output, and observing for signs of infection and subcutaneous emphysema are also important, ensuring tube patency takes precedence as it directly impacts the patient's respiratory status and overall safety.
3. What is the best approach to assist a client in performing self-care after an acute myocardial infarction, when the client expresses concern about fatigue?
- A. Provide clear instructions on how to ask for assistance
- B. Gradually resume self-care tasks, focusing on rest periods
- C. Encourage assistive personnel to complete self-care tasks
- D. Encourage the client to remain in bed until fully rested
Correct answer: B
Rationale: The best approach to assist a client in performing self-care after an acute myocardial infarction, especially when the client expresses concern about fatigue, is to gradually resume self-care tasks while focusing on rest periods. This approach allows the client to build confidence in managing their self-care activities while also addressing the issue of fatigue. Choice A is incorrect as it focuses on asking for assistance rather than promoting self-care. Choice C is inappropriate as it suggests delegating the client's self-care tasks to assistive personnel instead of empowering the client. Choice D is incorrect as it can lead to deconditioning and is not conducive to the client's recovery process.
4. A nurse is providing dietary teaching for a client with chronic kidney disease. What should be emphasized?
- A. Increase protein intake to promote healing
- B. Limit intake of potassium and phosphorus
- C. Increase fluid intake to prevent dehydration
- D. Encourage the intake of high-sodium foods
Correct answer: B
Rationale: The correct answer is to emphasize limiting the intake of potassium and phosphorus for a client with chronic kidney disease. Excessive intake of potassium and phosphorus can lead to complications in kidney disease patients. Choice A is incorrect because increasing protein intake can put additional stress on the kidneys. Choice C is incorrect as excessive fluid intake can worsen kidney function in such clients. Choice D is incorrect as encouraging high-sodium foods can lead to fluid retention and hypertension, which are not beneficial for individuals with chronic kidney disease.
5. A nurse is reinforcing teaching about wound care for a client who has a wound requiring irrigation. What is an important instruction?
- A. Wear sterile gloves when applying a new dressing
- B. Cleanse the wound from the center outwards
- C. Keep the wound dry between dressing changes
- D. Apply an antimicrobial ointment to the wound
Correct answer: B
Rationale: The correct answer is to cleanse the wound from the center outwards. This technique helps reduce the risk of contamination by pushing debris away from the wound. Option A, wearing sterile gloves, is important for infection control but not specifically related to wound irrigation. Option C, keeping the wound dry, is not suitable for wound irrigation, which often involves using solutions to clean the wound. Option D, applying an antimicrobial ointment, is not typically done during wound irrigation as the focus is on cleansing the wound.
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