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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 client receiving IV fluids has developed phlebitis. What action should the nurse take next after removing the IV catheter?
- A. Place a warm compress over the IV site
- B. Record the findings in the client's chart
- C. Notify the client's primary care provider
- D. Insert a new IV catheter
Correct answer: A
Rationale: After removing an IV catheter due to phlebitis, the next step is to apply a warm compress over the IV site. This helps reduce inflammation and discomfort for the client. Recording the findings in the client's chart is important for documentation purposes but not the immediate next step. Notifying the client's primary care provider may be necessary depending on the severity of the phlebitis, but it is not the initial action. Inserting a new IV catheter is not appropriate until the phlebitis has resolved.
3. What is the initial step a nurse should take when irrigating a wound?
- A. Wear sterile gloves while removing the old dressing
- B. Cleanse the wound from the center outward
- C. Apply a warm compress to the wound
- D. Use a 20 mL syringe to irrigate the wound
Correct answer: B
Rationale: The correct first action when irrigating a wound is to cleanse the wound from the center outward. This method helps remove debris and pathogens effectively, reducing the risk of infection. Choice A is incorrect because wearing sterile gloves should be done before starting the wound irrigation but is not the first action in the process. Choice C is incorrect as applying a warm compress is not the initial step in wound irrigation. Choice D is also incorrect as using a syringe to irrigate the wound comes after cleansing the wound.
4. A nurse is caring for a female client who has an indwelling urinary catheter. Which of the following actions should the nurse take?
- A. Position the drainage bag below the bladder
- B. Wipe the drainage port after emptying
- C. Insert the catheter using sterile technique
- D. Avoid cleansing the urinary meatus
Correct answer: B
Rationale: The correct answer is to wipe the drainage port after emptying. This action helps reduce the risk of infection by maintaining cleanliness. Positioning the drainage bag below the bladder (choice A) is incorrect as it should be positioned below the level of the bladder to prevent backflow of urine. Inserting the catheter using sterile technique (choice C) is not necessary for routine emptying of the drainage bag. Avoiding cleansing the urinary meatus (choice D) is incorrect as proper hygiene should be maintained to prevent infections.
5. A client is undergoing radiation therapy. Which of the following actions should the nurse take to prevent skin irritation?
- A. Apply heat packs to the area
- B. Use perfumed soap to cleanse the area
- C. Keep the area moist with lotion
- D. Avoid sun exposure to the treated area
Correct answer: D
Rationale: Avoiding sun exposure is crucial to prevent skin irritation and burns in clients undergoing radiation therapy. Radiation therapy makes the skin more sensitive to sunlight, increasing the risk of skin damage. Applying heat packs (choice A) can exacerbate skin irritation as heat can further irritate the skin that is already sensitive due to radiation. Using perfumed soap (choice B) can further irritate the skin due to its harsh chemicals, potentially worsening skin reactions. While keeping the area moist with lotion (choice C) may seem beneficial, some lotions contain ingredients that can worsen skin reactions during radiation therapy. Therefore, avoiding sun exposure to the treated area (choice D) is the most appropriate action to prevent skin irritation and damage during radiation therapy.
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