Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
The home health nurse visits a patient with a diagnosis of type 1 diabetes mellitus. The patient reports a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the patient indicates a need for further teaching?
A. "I was monitoring my blood glucose every 3 to 4 hours."
This is an appropriate patient action, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management. Therefore, this is not an indication of further teaching.
B. "I had to stop my insulin."
When a patient with type 1 diabetes mellitus experiences vomiting, diarrhea, and has not consumed food for 24 hours, it is likely that their blood glucose levels have dropped significantly. If insulin treatment continues at the same dosage, hypoglycemia may occur. Therefore, stopping insulin treatment can be dangerous and is an indication for further teaching.
C. "I called the doctor because of these symptoms."
This is an appropriate patient action, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management. Therefore, this is not an indication of further teaching.
D. None of the above.
This question is an excerpt from Nurse Dive's nursing test bank - PNU Adult Health II Spring 2023 Proctored Exam 2. Take the full exam now
Full Explanation
When a patient with type 1 diabetes mellitus experiences vomiting, diarrhea, and has not consumed food for 24 hours, it is likely that their blood glucose levels have dropped significantly. If insulin treatment continues at the same dosage, hypoglycemia may occur. Therefore, stopping insulin treatment can be dangerous and is an indication for further teaching. Choices A and C are appropriate patient actions, indicating that the patient is monitoring the blood glucose levels and has reached out to their doctor for further management.
Therefore, these are not indications for further teaching.
Similar Questions
A nurse is caring for a patient who is undergoing initial peritoneal dialysis. Which of the following should the nurse report immediately to the provider?
A. Blood-tinged dialysate outflow.
A) Blood-tinged dialysate outflow. While blood-tinged outflow can be concerning, it may not always indicate a severe complication, especially if it is minimal. It should be monitored and documented, but it does not require immediate reporting unless it becomes excessive.
B. Cloudy dialysate outflow.
B) Cloudy dialysate outflow. This finding is significant and warrants immediate reporting to the provider as it may indicate peritonitis, an infection of the peritoneal cavity. Prompt intervention is critical to address potential complications associated with dialysis.
C. Dialysate leakage during inflow.
C) Dialysate leakage during inflow. Dialysate leakage can occur and might be due to improper catheter placement or other issues. While it requires attention, it is not as urgent as cloudy dialysate outflow and can typically be managed without immediate escalation.
D. Report of discomfort during dialysate inflow.
D) Report of discomfort during dialysate inflow. Mild discomfort during inflow can be common, especially in the initial stages of peritoneal dialysis. It should be noted and assessed, but it does not necessarily require immediate reporting unless it is severe or persistent.
Full Explanation
Answer: B. Cloudy dialysate outflow.
Rationale:
A) Blood-tinged dialysate outflow.
While blood-tinged outflow can be concerning, it may not always indicate a severe complication, especially if it is minimal. It should be monitored and documented, but it does not require immediate reporting unless it becomes excessive.
B) Cloudy dialysate outflow.
This finding is significant and warrants immediate reporting to the provider as it may indicate peritonitis, an infection of the peritoneal cavity. Prompt intervention is critical to address potential complications associated with dialysis.
C) Dialysate leakage during inflow.
Dialysate leakage can occur and might be due to improper catheter placement or other issues. While it requires attention, it is not as urgent as cloudy dialysate outflow and can typically be managed without immediate escalation.
D) Report of discomfort during dialysate inflow.
Mild discomfort during inflow can be common, especially in the initial stages of peritoneal dialysis. It should be noted and assessed, but it does not necessarily require immediate reporting unless it is severe or persistent.
A nurse is caring for a patient who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)?
A. Amnesia.
This is not necessarily indicative of increased ICP
B. Tachycardia.
This is not necessarily indicative of increased ICP
C. Altered level of consciousness.
Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.
D. Hypotension.
Hypotension is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.
Full Explanation
Altered level of consciousness (LOC). Increased ICP can cause decreased LOC or changes in mental status, including confusion, agitation, or coma.
Options A, amnesia, and B, tachycardia, are not necessarily indicative of increased ICP, while option D, hypotension, is actually a sign of decreased ICP. Monitoring for elevated ICP is critical in patients with traumatic brain injury, and early recognition and intervention can be lifesaving. The nurse should report any changes in the patient's level of consciousness or other neurological symptoms to the provider immediately.
A nurse is caring for a patient with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, by which of the following times should the nurse ensure the patient receives breakfast?
A. 0720.
0720 is incorrect because it is too soon after the injection and the insulin may not have reached its onset of action yet.
B. 0815.
0815 is incorrect because it is too late after the injection and the insulin may have reached its peak effect by then, increasing the risk of hypoglycemia.
C. 0745.
0745.. Regular insulin has an onset of action of 30 to 60 minutes, a peak effect of 2 to 4 hours, and a duration of action of 6 to 8 hours. Therefore, the patient should receive breakfast within 30 minutes of receiving the insulin injection to prevent hypoglycemia.
D. 0730.
0730.is incorrect because it is less than 30 minutes after the injection and the insulin may be approaching its peak effect.
Full Explanation
0745.. Regular insulin has an onset of action of 30 to 60 minutes, a peak effect of 2 to 4 hours, and a duration of action of 6 to 8 hours. Therefore, the patient should receive breakfast within 30 minutes of receiving the insulin injection to prevent hypoglycemia.
Choice A. 0720 is incorrect because it is too soon after the injection and the insulin may not have reached its onset of action yet.
Choice B. 0815 is incorrect because it is too late after the injection and the insulin may have reached its peak effect by then, increasing the risk of hypoglycemia.
Choice D. 0730. is incorrect because it is less than 30 minutes after the injection and the insulin may be approaching its peak effect.