Prep-U Questions

A client's fasting blood sugar (FBS) is 63 mg/dL (3.5 mmol/L) at 0700. The client is alert and oriented. What should the nurse do first?

Give 15 g of carbohydrate and recheck the blood glucose in 15 minutes. According to American Diabetes Association (Canadian Diabetes Association) guidelines for treating hypoglycemia, the conscious adult client should be given 15 g of carbohydrate with a follow-up blood glucose level in 15 minutes. The other options do not follow these guidelines.

A child with rheumatic fever has chorea. Which of the following nursing actions is most important?

Explain to the child and family that the chorea will disappear over time. Because the clumsiness and uncontrolled actions can be upsetting to both the child and family, they need to understand that chorea associated with rheumatic fever is not permanent. Measures to keep the child in a warm environment are unnecessary because the child's cardiac workload will increase as the child attempts to remain cool. Neurologic assessments every 4 hours are not necessary because chorea is self-limiting and nonprogressive. Because the child has cardiac involvement, ambulation is contraindicated to minimize the increased oxygen demands on the heart. Aspirin is used primarily as an anti-inflammatory drug and secondarily for pain relief.

While palpating a client's right upper quadrant (RUQ), the nurse would expect to find which structure?

Liver The RUQ contains the liver, gallbladder, duodenum, head of the pancreas, hepatic flexure of the colon, portions of the ascending and transverse colon, and a portion of the right kidney. The sigmoid colon is located in the left lower quadrant; the appendix, in the right lower quadrant; and the spleen, in the left upper quadrant.

A nurse in the emergency department is caring for a client with acute heart failure. Which laboratory value is most important for the nurse to check before administering medications to treat heart failure?

Potassium Diuretics, such as furosemide, are commonly used to treat acute heart failure. Most diuretics increase the renal excretion of potassium. The nurse should check the client's potassium level before administering diuretics, and obtain an order to replace potassium if the level is low. Other medications commonly used to treat heart failure include angiotensin-converting enzyme inhibitors, digoxin, and beta-adrenergic blockers. Although checking the platelet count, calcium level, and WBC count are important, these values don't affect medication administration for acute heart failure.

Before performing an otoscopic examination on a child, where should the nurse palpate for tenderness?

Tragus, mastoid process, and helix Before inserting the otoscope, the nurse should palpate the child's external ear, especially the tragus and mastoid process, and should pull the helix backward to determine the presence of pain or tenderness. The umbo, incus, and malleus (parts of the middle ear) and the cochlea (part of the inner ear) aren't palpable.

During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's:

blood pressure. Control of blood pressure is critical during the first 24 hours after treatment because an intracerebral hemorrhage is the major adverse effect of thrombolytic therapy. Vital signs are monitored, and blood pressure is maintained as identified by the health care provider (HCP) and specific to the client's ischemic tissue needs and risk of bleeding from treatment. The other vital signs are important, but the priority is to monitor blood pressure.

The emergency department nurse has admitted an infant with bulging fontanels, setting sun eyes, and lethargy. Which diagnostic procedure would be contraindicated in this infant?

lumbar puncture The child is exhibiting signs and symptoms of increased intracranial pressure (ICP). A lumbar puncture is contraindicated in children with increased ICP due to the risk of herniation.

The nurse is caring for a client in the medical unit. The nurse receives a physician's order for Hydrocortisone 100 mg I.V. at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse is most correct to understand that this treatment is common in clients with which disease process?

Addison's disease. I.V. hydrocortisone for clients in acute adrenal crisis is the proper treatment for individuals with Addison's disease. Cushing's syndrome is associated with excessive amounts of glucocorticoids. Hyperthyroidism and hypoparathyroidism are not treated with hydrocortisone.