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A nurse is preparing to administer heparin subcutaneously to a client who has deep vein thrombosis. Which of the following actions should the nurse take?
- A. Insert the needle at a 90-degree angle.
- B. Massage the injection site after administering the heparin.
- C. Prepare for a blood test prior to injecting the heparin.
- D. Select a 22-gauge needle for heparin administration.
Correct Answer: A
Rationale: Correct Answer: A: Insert the needle at a 90-degree angle.
Rationale: When administering heparin subcutaneously, the nurse should insert the needle at a 90-degree angle to ensure proper delivery of the medication into the subcutaneous tissue. This angle allows for optimal absorption and effectiveness of the medication. Additionally, it minimizes the risk of injecting the medication into muscle tissue, which could lead to complications.
Summary of other choices:
B: Massaging the injection site after administering heparin is not recommended as it can cause bruising or discomfort.
C: There is no need to prepare for a blood test prior to injecting heparin subcutaneously.
D: A 22-gauge needle is too large for subcutaneous injection and can cause pain and tissue damage.
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A nurse is collecting data from a client who has diabetes mellitus. The client is confused, flushed, and has an acetone odor on their breath. The nurse should anticipate a prescription for which of the following types of insulin to treat the client.
- A. Regular insulin.
- B. NPH insulin.
- C. Lispro insulin.
- D. Glargine insulin.
Correct Answer: A
Rationale: The correct answer is A: Regular insulin. In this scenario, the client is showing symptoms of diabetic ketoacidosis (DKA), which is characterized by confusion, flushing, and acetone breath odor. Regular insulin is a short-acting insulin that is used to rapidly lower blood glucose levels in emergency situations like DKA. It acts quickly to reduce ketone production and stabilize the client's condition. NPH, Lispro, and Glargine insulins are not appropriate for treating DKA as they have different onset and duration of action, which are not suitable for managing acute hyperglycemia and ketosis.
A nurse in a provider's office is collecting data from a client who has hypothyroidism. Which of the following should the nurse expect?
- A. Bradycardia.
- B. Moist skin.
- C. Blurred vision.
- D. Insomnia.
Correct Answer: A
Rationale: The correct answer is A: Bradycardia. In hypothyroidism, there is a decrease in thyroid hormone production, leading to a slowed metabolism. This results in bradycardia, or a slow heart rate, as the thyroid hormone plays a role in regulating heart function. Moist skin (B), blurred vision (C), and insomnia (D) are not typically associated with hypothyroidism; instead, dry skin, vision changes, and fatigue are more common symptoms.
A nurse is reinforcing teaching with a client who is to start subcutaneous heparin. Which of the following information should the nurse include in the teaching?
- A. Use a soft-bristled toothbrush.
- B. Inject the medication deep into the thigh muscle.
- C. Expect stools to become black and tarry.
- D. Easy bruising indicates the medication is effective.
Correct Answer: A
Rationale: The correct answer is A: Use a soft-bristled toothbrush. When starting subcutaneous heparin, it is important to minimize the risk of bleeding. Using a soft-bristled toothbrush helps prevent gum bleeding. Choice B is incorrect because heparin is typically injected into the subcutaneous tissue, not deep into the muscle. Choice C is incorrect because black, tarry stools are a sign of gastrointestinal bleeding, not a side effect of heparin. Choice D is incorrect because easy bruising is not an indication of heparin's effectiveness, but rather a side effect indicating a need to adjust the dosage.
A nurse is preparing to administer insulin lispro to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse plan to take?
- A. Inject insulin lispro 15 min before a meal.
- B. Monitor the client for polyuria after the insulin lispro injection.
- C. Check the expiration date after the insulin lispro specification.
- D. Administer using a syringe with no washing.
Correct Answer: A
Rationale: The correct answer is A: Inject insulin lispro 15 min before a meal. This is because insulin lispro is a rapid-acting insulin that should be administered within 15 minutes before a meal to control postprandial glucose levels effectively. Administering it before a meal ensures that the insulin peaks when the client's blood glucose levels rise after eating, thus preventing hyperglycemia. Monitoring for polyuria (choice B) is important but not specific to insulin lispro administration. Checking the expiration date (choice C) is necessary but not directly related to the administration process. Administering insulin without washing the syringe (choice D) is incorrect as proper hygiene is essential to prevent infections.
A male client tells the nurse that he does not want the female assistive personnel (AP) involved in his care. Which of the following statements should the nurse give?
- A. Don't you trust a female AP assigned to your care?
- B. I understand your request to have only male staff members attend to your care.
- C. It's not appropriate to make such a request. All staff members are trained to provide professional care regardless of gender.
- D. I'll arrange for a male AP to do your personal care since you asked for it.
Correct Answer: B
Rationale: Correct Answer: B
Rationale: Option B acknowledges the client's preference in a respectful and empathetic manner. By expressing understanding and addressing the client's request for male staff members, the nurse shows sensitivity to the client's comfort and autonomy. This response promotes a therapeutic relationship based on mutual respect and trust.
Summary:
A: This option is confrontational and does not validate the client's feelings or concerns.
C: While this option emphasizes professionalism, it does not address the client's specific request and lacks empathy.
D: This option assumes the client's preference without validating his choice or showing understanding.
Options E, F, G: Not provided, but they would likely be incorrect as they do not address the client's request for male staff members.