Three hours after surgery, the nurse note that the breath of the client who is a type 1 diabetic has a "fruity" odor. What is the nurse's best first action?
A. Document the finding as the only action.
B. Increase the IV fluid flow rate.
C. Test the urine for ketone bodies.
D. Perform oral care.
C
The stress of surgery increases the action of counterregulatory hormones and suppresses the ac-tion of insulin, predisposing the client to ketoacidosis and metabolic acidosis.
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After teaching a client with acromegaly who is scheduled for a hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching?
a. "I will no longer need to limit my fluid intake after surgery." b. "I am glad no visible incision will result from this surgery." c. "I hope I can go back to wearing size 8 shoes instead of size 12." d. "I will wear slip-on shoes after surgery to limit bending over."
The nursing student is observing a staff nurse demonstrating a subcutaneous injection during a skills competency fair. The student tells the nurse that nursing textbooks indicate that aspirating for blood is not necessary
The nurse replies, "I prefer to check for blood, just in case. This is the way I learned to give shots and it works for me." The nurse's response is most likely related to: a. illogical thinking. b. a bias. c. closed-mindedness. d. an erroneous assumption.
In the morning care conference, the nurse instructs the assistant to feed breakfast to the clients in beds 2234, 2230, and 2241. The assistant indicates understanding of the assignment and repeats the bed numbers back to the nurse
What is the nurse's next step? 1. Check with the assistant to see how the assignment is going during the time breakfast is served. 2. Check the client's breakfast trays before they are returned to dietary. 3. Check with the clients to see if they had breakfast. 4. At the end of the shift ask the assistant how the clients ate.
A client is suspected to have Lyme disease and has a red macule at the site of the tick bite with a bull's-eye rash with round rings surrounding the center. In addition, the client has a severe headache with neck stiffness
What stage of Lyme disease is the client experiencing? A) Early stage 1 B) Midstage C) Later stage D) Latent stage