Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse suspects that a client who has diabetes mellitus is experiencing hypoglycemia.
Which of the following assessment findings supports this suspicion?
A. Cool, clammy skin.
This statement indicates an understanding of the teaching because cool, clammy skin is a common symptom of hypoglycemia.
B. Acetone breath.
Choice B is incorrect because acetone breath is a symptom of hyperglycemia (high blood sugar), not hypoglycemia (low blood sugar).
C. Kussmaul respirations.
Choice C is incorrect because Kussmaul respirations (deep and labored breathing) are a symptom of hyperglycemia, not hypoglycemia.
D. Increased urine output.
Choice D is incorrect because increased urine output is a symptom of hyperglycemia, not hypoglycemia.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Adult Medical Surgical 2019 Proctored Exam. Take the full exam now
Full Explanation
This statement indicates an understanding of the teaching because cool, clammy skin is a common symptom of hypoglycemia.
Choice B is incorrect because acetone breath is a symptom of hyperglycemia (high blood sugar), not hypoglycemia (low blood sugar).
Choice C is incorrect because Kussmaul respirations (deep and labored breathing) are a symptom of hyperglycemia, not hypoglycemia.
Choice D is incorrect because increased urine output is a symptom of hyperglycemia, not hypoglycemia.
Similar Questions
A nurse in a clinic is providing preventive teaching to an older adult client during a good visit.
The nurse should instruct the client that which of the following immunizations are recommended for healthy adults after age 60. (Select all that apply.).
A. Pneumococcal polysaccharide.
“Pneumococcal polysaccharide,” “Influenza,” and “Herpes zoster.” These statements indicate an understanding of the teaching because these immunizations are recommended for healthy adults after age 60.
B. Meningococcal.
Choice B is incorrect because the meningococcal vaccine is not typically recommended for healthy adults after age 60.
C. Human papillomavirus.
Choice C is incorrect because the human papillomavirus (HPV) vaccine is not typically recommended for healthy adults after age 60.
D. Influenza.
“Pneumococcal polysaccharide,” “Influenza,” and “Herpes zoster.” These statements indicate an understanding of the teaching because these immunizations are recommended for healthy adults after age 60.
E. Herpes zoster.
“Pneumococcal polysaccharide,” “Influenza,” and “Herpes zoster.” These statements indicate an understanding of the teaching because these immunizations are recommended for healthy adults after age 60.
Full Explanation
“Influenza,” and “Herpes zoster.” These statements indicate an understanding of the teaching because these immunizations are recommended for healthy adults after age 60.
Choice B is incorrect because the meningococcal vaccine is not typically recommended for healthy adults after age 60.
Choice C is incorrect because the human papillomavirus (HPV) vaccine is not typically recommended for healthy adults after age 60.
A nurse is teaching a client who has AIDS and wishes to continue self-care at home despite living alone.
Which of the following actions by the nurse demonstrates client advocacy?
A. Tell the client to avoid places where there are large crowds of people.
Choice A is wrong because avoiding large crowds of people is a precautionary measure but does not demonstrate client advocacy.
B. Instruct the client to avoid eating raw vegetables.
Choice B is wrong because avoiding raw vegetables is a dietary recommendation but does not demonstrate client advocacy.
C. Remind the client of the importance of medication adherence.
Choice C is wrong because reminding the client of the importance of medication adherence is important but does not demonstrate client advocacy.
D. Initiate a referral for the client to a home health agency.
Initiate a referral for the client to a home health agency. This action demonstrates client advocacy because it empowers the client to continue self-care at home while also providing them with additional support and resources through the home health agency.
Full Explanation
Initiate a referral for the client to a home health agency.
This action demonstrates client advocacy because it empowers the client to continue self-care at home while also providing them with additional support and resources through the home health agency.
Choice A is wrong because avoiding large crowds of people is a precautionary measure but does not demonstrate client advocacy.
Choice B is wrong because avoiding raw vegetables is a dietary recommendation but does not demonstrate client advocacy.
Choice C is wrong because reminding the client of the importance of medication adherence is important but does not demonstrate client advocacy.
A community health nurse is reviewing home care instructions with an older adult client who has a new diagnosis of heart failure.
Which of the following is the priority topic for the nurse to review with the client?
A. Daily exercise routine.
Choice A is wrong because while daily exercise is important for overall health, it is not the priority topic for the nurse to review with the client.
B. Daily sodium restrictions.
Choice B is wrong because while daily sodium restrictions are important for managing heart failure, it is not the priority topic for the nurse to review with the client.
C. Fluid intake record.
Choice C is wrong because while monitoring fluid intake is important for managing heart failure, it is not the priority topic for the nurse to review with the client.
D. Changes in weight.
The priority topic for the nurse to review with the client is monitoring changes in weight. A sudden weight gain may mean that the client’s heart failure is getting worse and they should call their doctor if they have a sudden weight gain, such as more than 2 to 3 pounds in a day or 5 pounds in a week.
Full Explanation
The priority topic for the nurse to review with the client is monitoring changes in weight.
A sudden weight gain may mean that the client’s heart failure is getting worse and they should call their doctor if they have a sudden weight gain, such as more than 2 to 3 pounds in a day or 5 pounds in a week.
Choice A is wrong because while daily exercise is important for overall health, it is not the priority topic for the nurse to review with the client.
Choice B is wrong because while daily sodium restrictions are important for managing heart failure, it is not the priority topic for the nurse to review with the client.
Choice C is wrong because while monitoring fluid intake is important for managing heart failure, it is not the priority topic for the nurse to review with the client.