Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is assessing a client who has diabetes mellitus and reports feeling dizzy and weak. Which of the following actions should the nurse take?
A. Check blood glucose level.
Checking blood glucose level is an appropriate action for the nurse to take because it can help determine if the client has hypoglycemia or hyperglycemia, which are both complications of diabetes mellitus that can cause dizziness and weakness. Blood glucose level should be checked using a glucometer and compared with the normal range of 70 to 130 mg/dL before meals and less than 180 mg/dL after meals.
B. Give insulin injection.
Giving insulin injection is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hypoglycemia, which is a condition in which blood glucose level drops below 70 mg/dL and can cause dizziness, weakness, confusion, sweating, and seizures. Insulin injection should be given according to the prescribed dose, type, and schedule.
C. Offer orange juice.
Offering orange juice is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hyperglycemia, which is a condition in which blood glucose level rises above 180 mg/dL and can cause dizziness, weakness, thirst, polyuria, and ketoacidosis. Orange juice should be offered only if the client has hypoglycemia and is conscious and able to swallow.
D. Apply cold compress.
Applying cold compress is not an appropriate action for the nurse to take because it does not address the underlying cause of dizziness and weakness in a client who has diabetes mellitus. Cold compress may worsen the symptoms by reducing blood flow and oxygen delivery to the brain. Cold compress should be applied only if the client has fever, inflammation, or pain.
This question is an excerpt from Nurse Dive's nursing test bank - RN Nutrition 2019 Nexy Updated 2023 Proctored Exam. Take the full exam now
Full Explanation
Choice A reason: Checking blood glucose level is an appropriate action for the nurse to take because it can help determine if the client has hypoglycemia or hyperglycemia, which are both complications of diabetes mellitus that can cause dizziness and weakness. Blood glucose level should be checked using a glucometer and compared with the normal range of 70 to 130 mg/dL before meals and less than 180 mg/dL after meals.
Choice B reason: Giving insulin injection is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hypoglycemia, which is a condition in which blood glucose level drops below 70 mg/dL and can cause dizziness, weakness, confusion, sweating, and seizures. Insulin injection should be given according to the prescribed dose, type, and schedule.
Choice C reason: Offering orange juice is not an appropriate action for the nurse to take without checking blood glucose level first because it may cause hyperglycemia, which is a condition in which blood glucose level rises above 180 mg/dL and can cause dizziness, weakness, thirst, polyuria, and ketoacidosis. Orange juice should be offered only if the client has hypoglycemia and is conscious and able to swallow.
Choice D reason: Applying cold compress is not an appropriate action for the nurse to take because it does not address the underlying cause of dizziness and weakness in a client who has diabetes mellitus. Cold compress may worsen the symptoms by reducing blood flow and oxygen delivery to the brain. Cold compress should be applied only if the client has fever, inflammation, or pain.
Similar Questions
A nurse is teaching a client who has difficulty chewing due to ill-fitting dentures. Which of the following foods should the nurse recommend for the client?
A. Scrambled eggs
Scrambled eggs are a good food choice for a client who has difficulty chewing due to ill-fitting dentures because they are soft, moist, and easy to swallow. Scrambled eggs also provide protein, iron, and vitamin B12 for the client.
B. Tuna fish
Tuna fish is not a good food choice for a client who has difficulty chewing due to ill-fitting dentures because it may contain bones, skin, or scales that can cause discomfort or injury to the gums or mouth. Tuna fish should be avoided or checked for bones and skin before consuming.
C. Roast beef
Roast beef is not a good food choice for a client who has difficulty chewing due to ill-fitting dentures because it is tough, dry, and hard to chew. Roast beef can cause pain, fatigue, or choking for the client who has ill-fitting dentures. Roast beef should be avoided or cut into very small pieces and moistened with gravy or sauce before consuming.
D. Apple slices
Apple slices are not a good food choice for a client who has difficulty chewing due to ill-fitting dentures because they are crisp, firm, and sticky. Apple slices can dislodge or damage the dentures or cause irritation or infection to the gums or mouth. Apple slices should be avoided or cooked until soft and mashed before consuming.
Full Explanation
Choice A reason: Scrambled eggs are a good food choice for a client who has difficulty chewing due to ill-fitting dentures because they are soft, moist, and easy to swallow. Scrambled eggs also provide protein, iron, and vitamin B12 for the client.
Choice B reason: Tuna fish is not a good food choice for a client who has difficulty chewing due to ill-fitting dentures because it may contain bones, skin, or scales that can cause discomfort or injury to the gums or mouth. Tuna fish should be avoided or checked for bones and skin before consuming.
Choice C reason: Roast beef is not a good food choice for a client who has difficulty chewing due to ill-fitting dentures because it is tough, dry, and hard to chew. Roast beef can cause pain, fatigue, or choking for the client who has ill-fitting dentures. Roast beef should be avoided or cut into very small pieces and moistened with gravy or sauce before consuming.
Choice D reason: Apple slices are not a good food choice for a client who has difficulty chewing due to ill-fitting dentures because they are crisp, firm, and sticky. Apple slices can dislodge or damage the dentures or cause irritation or infection to the gums or mouth. Apple slices should be avoided or cooked until soft and mashed before consuming.
Choice E reason: Dried fruit is not a good food choice for a client who has difficulty chewing due to ill-fitting dentures because they are chewy, sticky, and sugary. Dried fruit can adhere to the dentures or teeth and cause dental caries or gum disease. Dried fruit should be avoided or soaked in water until soft and cut into small pieces before consuming.
A nurse is caring for an older adult client who reports difficulty chewing due to missing teeth. Which of the following foods should the nurse recommend for the client?
A. Tuna fish
Tuna fish is a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is soft, moist, and easy to swallow. Tuna fish also provides protein, omega-3 fatty acids, and vitamin D for the client.
B. Roast beef
Roast beef is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is tough, dry, and hard to chew. Roast beef can cause pain, fatigue, or choking for the client who has missing teeth. Roast beef should be avoided or cut into very small pieces and moistened with gravy or sauce before consuming.
C. Apple slices
Apple slices are not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are crisp, firm, and sticky. Apple slices can cause irritation or injury to the gums or mouth or dislodge any remaining teeth. Apple slices should be avoided or cooked until soft and mashed before consuming.
D. Dried fruit
Dried fruit is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are chewy, sticky, and sugary. Dried fruit can adhere to the gums or teeth and cause dental caries or gum disease. Dried fruit should be avoided or soaked in water until soft and cut into small pieces before consuming.
Full Explanation
Choice A reason: Tuna fish is a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is soft, moist, and easy to swallow. Tuna fish also provides protein, omega-3 fatty acids, and vitamin D for the client.
Choice B reason: Roast beef is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because it is tough, dry, and hard to chew. Roast beef can cause pain, fatigue, or choking for the client who has missing teeth. Roast beef should be avoided or cut into very small pieces and moistened with gravy or sauce before consuming.
Choice C reason: Apple slices are not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are crisp, firm, and sticky. Apple slices can cause irritation or injury to the gums or mouth or dislodge any remaining teeth. Apple slices should be avoided or cooked until soft and mashed before consuming.
Choice D reason: Dried fruit is not a good food choice for an older adult client who has difficulty chewing due to missing teeth because they are chewy, sticky, and sugary. Dried fruit can adhere to the gums or teeth and cause dental caries or gum disease. Dried fruit should be avoided or soaked in water until soft and cut into small pieces before consuming.
A nurse is caring for a client who has heart failure and has gained 2 kg (4.4 lB. over the last 24 hours. Which of the following interventions should the nurse take?
A. Reduce the client's sodium intake.
Reducing the client's sodium intake is an appropriate intervention for the nurse to take because it can help prevent fluid retention and edema, which are complications of heart failure. Sodium intake should be limited to 2 g per day or less for clients who have heart failure.
B. Restrict the client's protein intake.
Restricting the client's protein intake is not an appropriate intervention for the nurse to take because it can cause malnutrition and muscle wasting, which can worsen heart failure. Protein intake should be adequate to meet the client's nutritional needs and support cardiac function. Protein intake should be about 0.8 to 1.2 g per kg of body weight per day for clients who have heart failure.
C. Weigh the client once per week.
Weighing the client once per week is not an appropriate intervention for the nurse to take because it can delay the detection and treatment of fluid overload, which can worsen heart failure. The client should be weighed daily at the same time and with the same scale and clothing to monitor fluid status and adjust medication dosage.
D. Provide the client with three large meals per day.
Providing the client with three large meals per day is not an appropriate intervention for the nurse to take because it can increase the workload of the heart and cause dyspnea, fatigue, or chest pain, which are symptoms of heart failure. The client should be provided with small, frequent meals that are low in sodium, fat, and cholesterol to reduce cardiac stress and promote digestion.
Full Explanation
Choice A reason: Reducing the client's sodium intake is an appropriate intervention for the nurse to take because it can help prevent fluid retention and edema, which are complications of heart failure. Sodium intake should be limited to 2 g per day or less for clients who have heart failure.
Choice B reason: Restricting the client's protein intake is not an appropriate intervention for the nurse to take because it can cause malnutrition and muscle wasting, which can worsen heart failure. Protein intake should be adequate to meet the client's nutritional needs and support cardiac function. Protein intake should be about 0.8 to 1.2 g per kg of body weight per day for clients who have heart failure.
Choice C reason: Weighing the client once per week is not an appropriate intervention for the nurse to take because it can delay the detection and treatment of fluid overload, which can worsen heart failure. The client should be weighed daily at the same time and with the same scale and clothing to monitor fluid status and adjust medication dosage.
Choice D reason: Providing the client with three large meals per day is not an appropriate intervention for the nurse to take because it can increase the workload of the heart and cause dyspnea, fatigue, or chest pain, which are symptoms of heart failure. The client should be provided with small, frequent meals that are low in sodium, fat, and cholesterol to reduce cardiac stress and promote digestion.
