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1. What are the key signs of hyperglycemia?
- A. Increased thirst and frequent urination
- B. Decreased appetite and low blood pressure
- C. Weight loss and nausea
- D. Increased sweating and confusion
Correct answer: A
Rationale: The correct answer is A: Increased thirst and frequent urination. These are classic signs of hyperglycemia, indicating elevated blood sugar levels. Choice B is incorrect as hyperglycemia usually presents with increased appetite rather than decreased appetite and low blood pressure. Choice C is incorrect as weight loss is more commonly associated with uncontrolled diabetes rather than hyperglycemia. Choice D is incorrect as increased sweating and confusion are not typical signs of hyperglycemia.
2. 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.
3. A nurse is reinforcing teaching with a client who has dumping syndrome about measures to reduce manifestations. Which of the following instructions should the nurse include in the teaching?
- A. Drink plenty of fluids after meals
- B. Increase sugar intake
- C. Eat smaller, more frequent meals
- D. Avoid foods high in sugar content
Correct answer: D
Rationale: The correct instruction the nurse should include in teaching a client with dumping syndrome is to 'Avoid foods high in sugar content.' Dumping syndrome occurs when high-sugar foods move too quickly into the small intestine, leading to symptoms like abdominal cramps, diarrhea, and bloating. By avoiding foods high in sugar content, the client can reduce these symptoms. Choices A, B, and C are incorrect. Drinking plenty of fluids after meals may exacerbate symptoms by speeding up the movement of food through the digestive system. Increasing sugar intake would worsen dumping syndrome symptoms. While eating smaller, more frequent meals is a good strategy, the key emphasis should be on avoiding high-sugar foods.
4. A nurse assisting with a childbirth class is discussing nonpharmacological strategies used during labor. Which of the following statements by a client indicates an understanding of cutaneous stimulation?
- A. Apply counter-pressure for back pain
- B. Use deep breathing exercises
- C. Visualize the baby's head
- D. Use massage therapy
Correct answer: A
Rationale: The correct answer is A: 'Apply counter-pressure for back pain.' Counter-pressure involves applying pressure to the lower back to alleviate pain during labor. This technique is a form of cutaneous stimulation, which can help with pain relief. Choice B, deep breathing exercises, is a form of relaxation technique and does not directly involve cutaneous stimulation. Choice C, visualizing the baby's head, is a mental imagery technique and does not involve physical stimulation of the skin. Choice D, massage therapy, is a tactile stimulation technique but is not specifically focused on back pain relief through counter-pressure.
5. A client who is taking furosemide is being taught by a nurse about dietary modifications. Which of the following foods should the nurse recommend to the client?
- A. Bananas
- B. Cabbage
- C. Potatoes
- D. Carrots
Correct answer: A
Rationale: The correct answer is A, Bananas. Bananas are high in potassium, which is essential for clients taking furosemide to prevent hypokalemia. Furosemide is a diuretic that can cause potassium loss through increased urine output. Therefore, recommending foods rich in potassium, such as bananas, can help maintain potassium levels within the normal range. Choices B, C, and D are not the best recommendations in this case as they are not particularly high in potassium.
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