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15 NCLEX questions and ICP answers

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1 15 NCLEX questions and ICP answers on Thu Nov 03, 2011 3:20 pm

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15 NCLEX questions: Diabetes
Medical-Surgical Nursing: Review and Rationales by Mary Ann Hogan pg 496-497
1. The nurse is caring for a client with type 1 diabetes mellitus. In developing a teaching plan, which of the following signs and symptoms of hypoglycemia should the nurse include?
Shakiness
Increased thirst
Fever
Fruity breath
ANSWER: A
2. A diabetic client with the flu asks why he should drink juices, check his fingerstick glucose every 4 hours, and take insulin when he is not eating and is vomiting. What would be the best explanation by the nurse?
“ You need to prevent dehydration and monitor for hyperglycemia and excessive breakdown of fats for glucose
“You need to check your blood glucose because vomiting could cause hypoglycemia and drinking fluids will prevent dehydration.”
“Your body uses protein for energy during times of illness, causing increased ketones and hypoglycemia.”
“If you can substitute water for the juices to prevent dehydration, then you won’t need to check your blood glucose levels so often.”
ANSWER: A
3. The client with diabetic ketoacidosis is given intravenous normal saline infusion and regular insulin. In addition to hourly blood glucose monitoring, the nurse would look to what assessment data as early signs of clinical improvement?
Respiratory rate of 12-15 and normal BP in standing position
Temperature and pulse in normal range
Improved level of consciousness and decreasing urine output
Client eats a full meal and respiratory rate is normal
ANSWER: C
4. The nurse is caring for a client who is taking 4 units of regular insulin and 30 units of NPH insulin at 0800. The nurse keeps which of the following in mind regarding this regimen? Select all that apply
Client may experience hypoglycemia shortly after breakfast
Client may experience hypoglycemia at dinnertime.
Shake vial of insulin to disperse insulin particles evenly
Administer room temperature insulin only
Neither insulin can be administered intravenously
ANSWER: A, B, D
5. The nurse is preparing to discharge a client newly diagnosed with diabetes mellitus. The client states, “I should eat a candy bar or cup of ice cream every time I feel shaky, hungry, or nauseated.” What would be the best response by the nurse?
“Yes, a candy bar or cup of ice cream is needed to treat the hypoglycemia.”
“Yes, you should eat the snack, then have a meal as soon as possible.”
“No, you should quickly eat a meal; the candy will cause hyperglycemia.”
“No, these have too much sugar and fat; 5 Lifesavers candy or skim milk are better choices.”
ANSWER: D
NCLEX-Rn Review made Incredibly Easy by Lippincott Williams and Wilkins pg 311-312
6. A client with type 1 diabetes mellitus is learning foot care. The nurse should include which teaching point?
“It’s OK to go barefoot at home.”
“Trim your toenails with scissors regularly.”
“Wear tight-fitting shoes without socks.”
“Wear cotton socks and apply foot powder to your feet to keep them dry.”
ANSWER: D
7. Which nursing diagnosis is most likely for a client with an acute episode of diabetes insipidus?
Imbalanced Nutrition: More than body requirements
Deficient fluid volume
Impaired gas exchange
Ineffective tissue perfusion
ANSWER: B
Child Health Nursing: Review and Rationales by Mary Ann Hogan pg 180-181; 200-201
8. An 10 year old diabetic client tells the school nurse that he has some early signs of hypoglycemia. The nurse recommends that the child:
Take an extra injection of regular insulin
Drink a glass of orange juice
Skip the next dose of insulin
Start exercising
ANSWER: B
9. An adolescent with diabetes has had several episodes demonstrating lack of diabetic control. The nurse reviewing techniques for checking the control of diabetes. The nurse states to the adolescent, “The best way to maintain control of your disease is to:
Check your urine glucose three times a week.”
Check your glycosolated hemoglobin every 3 months and then every 6 months when stable.”
Check the blood glucose twice a day and the glycosolated hemoglobin every 3 months.”
Check glucose daily as long as you feel well.”
ANSWER: C
10. A mother attends the pediatric clinic with her 10 year old daughter who has diabetes mellitus. After completing the diabetic teaching, the nurse evaluates the mother’s knowledge. Which statement by the mother indicates a satisfactory understanding of diabetes?
“ I worry about my daughter maintaining control since children with diabetes have more complications than adults do.”
“My daughter should drink vanilla milkshakes to maintain a high calorie intake.”
“Complications from diabetes could include cataracts and kidney stones.”
“My child won’t need a mid-afternoon snack since she takes a gym class in the afternoon.”
ANSWER: A
11. Considering a child’s development level in diabetic care is essential. The nurse should include which information in teaching the parents of a recently diagnosed toddler with diabetes? Select all that apply
Allow the toddler to assist with the daily insulin injections.
Prepare meat, vegetables, and potatoes for each dinner. The toddler cannot be allowed many choices in food selection.
Test the toddler’s blood glucose every time he goes outside to play.
Allow the toddler to assist with cleaning off his fingers before blood glucose monitoring.
Allow the toddler to choose food selections from options offered.
ANSWER: D,E
12. A 10 year old girl comes to the office of the school nurse after recess. This is the child’s first day back in school after hospitalization, where she was diagnoses with diabetes. The child reports she took the dose of insulin as instructed and that it was the same as she took while hospitalized. The nurse notices that she is nervous with hand tremors present. She is pale, sweaty, and complaining of sleepiness. The school nurse would suspect:
Exercise- induced hypoglycemia
Hyperglycemia caused by increased intake at lunch
Ketoacidosis caused by an infection
The child is avoiding returning to class
ANSWER: A
13. A 12 year old boy was just diagnosed with Type 1 diabetes mellitus. As the nurse teaches him about insulin injections, he asks why he can’t take the diabetic pills that his aunt takes. What would be the best response by the nurse?
“ You will be able to take the pills once you reach adult height.”
“ You have a different type of diabetes where the pill won’t hurt.”
“ We have to test you to see if you can take the diabetic pills.”
“You might be able to switch between taking the pills and insulin.”
ANSWER:B
ATI: RN Adult Medical Surgical Nursing pg 1106
14. A nurse is caring for a client whose bloood glucose is 49 mg/dL. The client is lethargic but arousable. Which of the following is the priority nursing action”
Re-check blood glucose in 15 minutes
Give 7 g of protein
Give 15-20 g of carbohydrates
Report findings to the client’s health care providers
ANSWER: C
15. A client’s medication record reads: Lispro insulin 10 unites subcutaneously 0800. Which of the following actions should the nurse take when administering this medication?
Check the client’s blood glucose immediately after administration
Administer the medication when the breakfast tray arrives
Administer the medication within 30 minutes of the scheduled time
Clarify the prescription because the medication is usually given at bedtime.
ANSWER: B

Earliest to late: 5 signs and symptoms of ICP
1. Blurred vision
2. Headache
3. Change in level of consciousness
4. Dramatic rise in temperature
5. Changes in respirations

Positions to avoid:
Prone/Supine
Left or Right Lateral Recumbent
Trendlenburg
** Always avoid positions that place neck in a flexed, hyperextended position. Ideal position is head midline with head of bed elevated 30 degrees. **
Medical-Surgical Nursing Reviews and Rationales pg 174-175/Powerpoint

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