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Questions 164

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Extract:

Laboratory reference ranges
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L)


Question 1 of 5

The nurse is caring for a client who has acute pancreatitis. Which of the following findings is most concerning?

Correct Answer: C

Rationale: Fever (102.2°F) with increasing abdominal pain suggests infection or abscess, a life-threatening complication of pancreatitis. Hyperglycemia, knee-flexed positioning, and diarrhea are concerning but less urgent.

Extract:


Question 2 of 5

A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?

Correct Answer: C

Rationale: Regular insulin is the only insulin that can be given by the intravenous route. Humulin N is not suitable for IV administration, making this the priority order to question.

Question 3 of 5

The nurse is reviewing new medication prescriptions for a client who has a suspected brain tumor. The client is scheduled for a CT scan of the head with IV iodinated contrast in 24 hours. The nurse should clarify the prescription for

Correct Answer: C

Rationale: Metformin should be held before and after iodinated contrast due to the risk of lactic acidosis if contrast-induced kidney injury occurs. Gabapentin, amlodipine, and phenytoin are safe with contrast.

Question 4 of 5

A veteran is admitted with a diagnosis of chronic post-traumatic stress disorder. After being placed in the treatment room, he begins to pace frantically and make references to 'highway one.' As the nurse approaches him, he retreats to the corner and sits on the floor with his arms and legs pulled tight to his body. The client is experiencing a:

Correct Answer: D

Rationale: The behavior and reference to 'highway one' suggest a flashback, where the client is reliving a traumatic event, common in PTSD.

Question 5 of 5

While caring for a child with Reye's syndrome, the nurse should give which action the highest priority?

Correct Answer: C

Rationale: Assess level of consciousness. An altered level of consciousness suggests increasing intracranial pressure related to cerebral edema.

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