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A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
- A. Repeat glycohemoglobin in 24 hours
- B. Document Accu-checks, intake and output every 4 hours
- C. Humulin N 20 units IV push
- D. IV fluids of 0.9% normal saline at 125 ml per hour
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.
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The nurse knows that the mother understands the dietary instructions for her toddler who has iron deficiency anemia when the mother selects which foods?
- A. Whole milk, carrots, and chicken pieces
- B. Ground beef, broccoli, and orange juice
- C. Liver, lima beans, and skim milk
- D. Macaroni and cheese, peas, and cola
Correct Answer: B
Rationale: Ground beef and broccoli are iron-rich, and orange juice (vitamin C) enhances iron absorption, ideal for iron deficiency anemia. Milk-heavy diets can inhibit iron absorption.
The nurse is preparing the sterile field and supplies for a wet-to-damp dressing change. Which of the following actions by the nurse would require follow-up?
- A. Drop sterile gauze on the sterile field from 6 inches (15cm ) above
- B. Keeps the sterile field and sterile gloved hands within view at all times
- C. Places sterile gauze 2 inches (5 cm) inside the outer edge of the sterile drape
- D. Pours sterile saline solution from a recapped bottle opened 30 hours ago
Correct Answer: D
Rationale: Using saline from a bottle opened 30 hours ago risks contamination, as sterile solutions are typically discarded after 24 hours. Keeping the field in view and placing gauze appropriately maintain sterility.
A 2-year-old child seen in the emergency department is dehydrated and malnourished. The child’s parent reports that the child has had diarrhea for the past 2 weeks. Which observation is of most concern to the nurse?
- A. The parent cannot stay at the hospital due to potential job loss if late for work
- B. The parent does not seem to be concerned about the child’s condition
- C. The parent is single
- D. The parent left a 3-year-old and a 5-year-old in the care of a 9-year-old
Correct Answer: D
Rationale: Leaving young children in the care of a 9-year-old poses significant safety risks, indicating neglect and requiring immediate intervention. Job constraints, lack of concern, and single status are concerning but less immediately dangerous.
The nurse is screening clients for those at risk for developing endometrial cancer. Which of the following clients is at highest risk for developing endometrial cancer?
- A. 42-year-old client who has been taking a progestin-containing oral contraceptive for 10 years
- B. 45-year-old client who has a history of one ectopic pregnancy and two births
- C. 51-year-old client who has polycystic ovary syndrome and is obese
- D. 54-year-old client who has a history of hysterectomy for uterine fibroids
Correct Answer: C
Rationale: Obesity and polycystic ovary syndrome (PCOS) increase endometrial cancer risk due to excess estrogen from adipose tissue and anovulation. Ectopic pregnancy and births are not significant risk factors.
A client is admitted to the coronary care unit with an acute myocardial infarction. The pain associated with acute myocardial infarction results from:
- A. Spasm of the coronary artery
- B. Ischemia of the myocardium
- C. Vasodilation of the coronary veins
- D. Ischemia of the carotid artery
Correct Answer: B
Rationale: Myocardial infarction pain is caused by ischemia of the myocardium due to reduced blood flow, leading to tissue hypoxia.