Glucose-Metabolism
A client with Type 1 Diabetes has a blood glucose of 52 mg/dL. Which action should the nurse take first?
A. Administer insulin
B. Recheck blood glucose in 30 minutes
C. Give 15g of a fast-acting carbohydrate
D. Notify the provider
Answer: C
Rationale: Blood glucose <70 mg/dL indicates hypoglycemia. The priority is rapid treatment with 15g of carbs per the "15-15 rule".
Which finding during abdominal assessment should be reported immediately?
A. 6 bowel sounds per minute
B. Tympany over the stomach
C. Rigid abdomen and absent bowel sounds
D. Soft abdomen with active bowel sounds
Answer: C
Rationale: Rigid abdomen and absent sounds may indicate obstruction or peritonitis—emergent conditions.
Which finding indicates Stage III pressure injury?
A. Red, non-blanchable skin
B. Partial-thickness skin loss
C. Full-thickness tissue loss with visible fat
D. Full-thickness with exposed bone
Answer: C
Rationale: Stage III involves full-thickness loss with fat visible.
Which lab result supports a diagnosis of hypothyroidism?
A. Decreased TSH, increased T4
B. Increased TSH, decreased T3/T4
C. Elevated cortisol
D. Decreased insulin levels
Answer: B
Rationale: In primary hypothyroidism, the thyroid fails, and TSH rises to compensate.
Which is an example of malpractice?
A. Administering medication without checking the 5 rights
B. Documenting late in the shift
C. Refusing to delegate to UAP
D. Calling the provider about a lab result
Answer: A
Rationale: Not verifying rights may cause harm—meeting malpractice criteria.
Which lab value best reflects long-term glucose control?
A. Fasting blood glucose
B. Hemoglobin
C. HbA1c
D. Serum insulin
Answer: C
Rationale: HbA1c reflects average blood glucose over 2–3 months.
Which intervention helps prevent constipation in an immobile patient?
A. Limiting fluid intake
B. Administering daily laxatives
C. Providing a high-fiber diet and fluids
D. Restricting physical movement
Answer: C
Rationale: Fiber and fluid intake help promote peristalsis and stool passage.
What action helps prevent pressure injury in a bedridden patient?
A. Massage reddened areas
B. Elevate head of bed >45°
C. Reposition every 2 hours
D. Use only cotton linens
Answer: C
Rationale: Frequent repositioning reduces prolonged pressure on bony areas.
Which symptom is associated with hyperthyroidism?
A. Cold intolerance and fatigue
B. Weight gain and dry skin
C. Heat intolerance and anxiety
D. Bradycardia and depression
Answer: C
Rationale: Increased metabolism causes heat intolerance and nervousness.
Which principle is reflected when a nurse ensures a patient can make informed choices?
A. Nonmaleficence
B. Autonomy
C. Justice
D. Fidelity
Answer: B
Rationale: Autonomy involves respecting the patient’s right to choose.
A patient newly diagnosed with Type 2 Diabetes asks how exercise helps manage blood sugar. The nurse responds:
A. "It reduces your pancreas' need to release insulin."
B. "It helps burn calories to reduce weight only."
C. "It increases insulin sensitivity in your cells."
D. "It eliminates the need for medication."
Answer: C
Rationale: Exercise improves insulin sensitivity, aiding glucose uptake by cells.
The nurse is assessing a patient with diarrhea. Which electrolyte imbalance is the priority concern?
A. Hypernatremia
B. Hyperkalemia
C. Hypokalemia
D. Hypocalcemia
Answer: C
Rationale: Diarrhea leads to loss of potassium, risking hypokalemia.
Which client is at highest risk for impaired skin integrity?
A. Young adult who jogs daily
B. Teen with acne
C. Older adult with diabetes and immobility
D. Middle-aged adult with a tattoo
Answer: C
Rationale: Age, diabetes, and immobility impair circulation and healing.
Which intervention is most important for a client with myxedema coma?
A. Monitor for dehydration
B. Administer IV levothyroxine
C. Encourage ambulation
D. Provide cooling blankets
Answer: B
Rationale: Myxedema coma is a life-threatening hypothyroid crisis requiring hormone replacement.
A nurse feels forced to follow a physician’s order that conflicts with their values. This is:
A. Burnout
B. Ethical dilemma
C. Moral distress
D. Negligence
Answer: C
Rationale: Moral distress is when nurses can't act according to their ethical beliefs.
Which patient is at highest risk for Type 2 diabetes?
A. 30-year-old male with a BMI of 22
B. 55-year-old female with central obesity and sedentary lifestyle
C. 20-year-old athlete with elevated HDL
D. 40-year-old with family history but no symptoms
Answer: B
Rationale: Central obesity, age, and inactivity are major risk factors.
What is the most appropriate intervention for bowel incontinence?
A. Administer antidiarrheals regularly
B. Insert a Foley catheter
C. Implement a bowel training program
D. Place patient on NPO status
Answer: C
Rationale: Bowel training supports regular elimination and preserves dignity.
A nurse observes black, dry tissue in a wound. This is known as:
A. Slough
B. Eschar
C. Granulation
D. Purulent exudate
Answer: B
Rationale: Eschar is black, dehydrated necrotic tissue.
What is the best indicator that a patient understands carbohydrate counting?
A. States carbs are not needed in diet
B. Accurately lists carb content of a meal
C. Avoids all sugars
D. Identifies only protein-rich foods
Answer: B
Rationale: Carbohydrate counting requires knowing the carb content of foods to manage glucose.
A patient asks why they need a colonoscopy at age 45. The nurse replies:
A. "It’s only needed if you have symptoms."
B. "It’s part of routine cancer screening recommendations."
C. "It diagnoses food allergies."
D. "It prevents ulcers."
Answer: B
Rationale: Screening for colorectal cancer begins at 45 in average-risk adults.
Which symptom suggests hypothermia?
A. Warm, flushed skin
B. Body temperature of 37.2°C
C. Shivering and confusion
D. Sweating and tachycardia
Answer: C
Rationale: Hypothermia signs include shivering, altered LOC, and cool skin.