Nokea
A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL (12.2 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take?
- A. Administer 20 units of NPH insulin now and then 6 units of regular insulin after the morning meal
- B. Administer 26 units of insulin: 20 units of NPH insulin and 6 units of regular insulin in 2 separate injections
- C. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the NPH into the syringe first
- D. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first
Correct Answer: D
Rationale: Regular insulin is drawn up first to prevent NPH contamination, and both can be mixed in one syringe for a blood glucose of 220 mg/dL, assuming a sliding scale of 6 units. Administering after the meal or using separate injections is incorrect.
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Which group of food selections would be appropriate for a client on a full liquid diet 3 days after bariatric surgery?
- A. Apple juice, mashed potatoes, and chocolate pudding
- B. Chicken broth, low-fat cheese omelet, and strawberry ice cream
- C. Creamy wheat cereal, blended cream of chicken soup, and a protein shake
- D. Low-fat vanilla yogurt, smooth peanut butter, and vegetable juice
Correct Answer: C
Rationale: Creamy wheat cereal, blended soup, and protein shakes are full liquids suitable post-bariatric surgery. The other options include solid foods.
The nurse is caring for a postoperative client with a Hemovac drain. Which task request is inappropriate for the nurse to make to the experienced unlicensed assistive personnel?
- A. Please change the sterile dressing on the Hemovac drain insertion site when you bathe the client
- B. Please measure the Hemovac drainage at 2:00 PM and let me know how much there was.
- C. Please record the amount of Hemovac drainage on the intake and output record at the end of the shift
- D. Please remember to compress the Hemovac device immediately after emptying it to restore negative pressure, as you were taught.
Correct Answer: A
Rationale: Changing a sterile dressing is a nursing task requiring sterile technique, inappropriate for unlicensed personnel. Measuring, recording, and compressing the Hemovac are within their scope.
The nurse is caring for an adult who is admitted with severe nausea, vomiting, and diarrhea. During the last eight hours, the client has had 1000 mL of IV fluids and 100 mL of fluid from ice chips. The client has vomited a total of 600 mL and had four large diarrheal stools. The urine output for the last eight hours is 350 mL. The best interpretation of these data is that the client:
- A. is maintaining an appropriate fluid balance.
- B. has a normal urine output.
- C. is at risk for dehydration.
- D. is at risk for fluid overload.
Correct Answer: C
Rationale: Significant fluid losses from vomiting and diarrhea exceed intake, and low urine output indicates dehydration risk.
The nurse is preparing to administer an enteral feeding to a client via a nasogastric feeding tube. The most important action of the nurse is to
- A. verify correct placement of the tube
- B. check that the feeding solution matches the dietary order
- C. aspirate abdominal contents to determine the amount of last feeding remaining in stomach
- D. ensure that feeding solution is at room temperature
Correct Answer: A
Rationale: verify correct placement of the tube. Proper placement of the tube prevents aspiration.
Which of the following should the nurse obtain from a client prior to having electroconvulsive therapy (ECT)?
- A. Permission to videotape
- B. Salivary pH
- C. Mini-mental status exam
- D. Pre-anesthesia work-up
Correct Answer: D
Rationale: Pre-anesthesia work-up. ECT is delivered under general anesthesia and the client should be prepared as for any procedure involving anesthesia.