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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. How should a healthcare provider assess a patient for fluid overload?
- A. Monitor weight and assess for shortness of breath
- B. Auscultate lung sounds and monitor blood pressure
- C. Assess for edema in the extremities
- D. Assess for jugular venous distension
Correct answer: A
Rationale: Correctly, the answer is to monitor weight and assess for shortness of breath when assessing a patient for fluid overload. Weight monitoring is crucial as sudden weight gain can indicate fluid retention. Shortness of breath can be a sign of fluid accumulation in the lungs. While auscultating lung sounds and monitoring blood pressure are important assessments in overall patient care, they may not be specific to fluid overload. Assessing for edema in the extremities is relevant, but it is not as sensitive as monitoring weight for detecting fluid overload. Assessing for jugular venous distension is more specific to assessing fluid status in heart failure rather than a general assessment for fluid overload.
3. What is the most important nursing action when administering IV potassium?
- A. Monitor for decreased urine output
- B. Administer via IV push
- C. Administer slowly and dilute in IV fluids
- D. Ensure the client drinks 500 mL of water before administration
Correct answer: C
Rationale: The most important nursing action when administering IV potassium is to administer it slowly and dilute it in IV fluids. This approach helps prevent irritation and hyperkalemia. Monitoring for decreased urine output (Choice A) is important but not as critical as ensuring the safe administration of IV potassium. Administering potassium via IV push (Choice B) is unsafe and can lead to adverse effects. Ensuring the client drinks water before administration (Choice D) is not directly related to the safe administration of IV potassium.
4. A nurse is contributing to the plan of care for a client who has a chest tube connected to a closed drainage system. Which of the following interventions should the nurse include?
- A. Clamp the chest tube
- B. Maintain the drainage below the level of the chest
- C. Elevate the chest tube above chest level
- D. Avoid frequent dressing changes
Correct answer: B
Rationale: The correct intervention for a client with a chest tube connected to a closed drainage system is to maintain the drainage below the level of the chest. This position allows proper drainage of fluids and helps prevent complications such as backflow of blood or fluids into the chest cavity. Clamping the chest tube (Choice A) is incorrect as it can lead to a tension pneumothorax. Elevating the chest tube above chest level (Choice C) is also incorrect because it can impede proper drainage. Avoiding frequent dressing changes (Choice D) is important to prevent introducing infection, but it is not directly related to the position of the drainage system.
5. A client is concerned about extreme fatigue after an acute myocardial infarction. What is the best strategy the nurse can suggest to promote independence in self-care?
- A. Encourage the client to rest and let the healthcare team take over self-care tasks
- B. Instruct the client to gradually resume self-care tasks, with rest periods
- C. Assign assistive personnel to complete self-care tasks for the client
- D. Ask the client's family to assist with self-care
Correct answer: B
Rationale: The best strategy to promote independence in self-care for a client concerned about extreme fatigue after an acute myocardial infarction is to instruct the client to gradually resume self-care tasks, with rest periods. This approach allows the client to regain independence without overexerting. Choice A is incorrect because encouraging the client to rest completely and letting the healthcare team take over self-care tasks may hinder independence. Choice C is incorrect as assigning assistive personnel to complete self-care tasks does not promote the client's independence. Choice D is not the best option as the primary focus should be on empowering the client to perform self-care tasks independently.
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