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A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Temperature
Correct Answer: B
Rationale: Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate.
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The client is instructed regarding foods that are low in fat and cholesterol. Which diet selection is lowest in saturated fats?
- A. Macaroni and cheese
- B. Shrimp with rice
- C. Turkey breast
- D. Spaghetti and meatballs
Correct Answer: C
Rationale: Turkey contains the least amount of fat and cholesterol. Cheese, shrimp, and beef should be avoided by the client on a low cholesterol, low fat diet; therefore, answers A, B, and D are incorrect.
Medication administration record
Allergies: No Known Allergies
Sliding scale blood glucose levels, regular insulin dose
<150 mg/dL (<8.3 mmol/L), O units
150-199 mg/dL (8.3-11.0 mmol/L), 2 units
200-249 mg/dL (11.1-13.8 mmoV/L), 4 units
250-299 mg/dL (13.9-16.6 mmol/L), 6 units
≥300 mg/dL (≥16.7 mmol/L), 8 units and notify health care provider
A client with type 1 diabetes has a prescription for 30 units of insulin glargine at bedtime. Fingerstick blood glucose measurements are prescribed before meals and at bedtime with regular insulin based on a sliding scale. At 9 PM, the client's blood glucose measurement is 180 mg/dL (10.0 mmol/L). What action should the nurse take?
- A. Administer 30 units of glargine; give the client a snack, then administer 2 units of regular insulin
- B. Administer 30 units of glargine and 2 units of regular insulin in 2 different injections
- C. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the glargine first
- D. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the regular insulin first
Correct Answer: B
Rationale: The sliding scale indicates 2 units of regular insulin for a glucose of 180 mg/dL. Glargine, a long-acting insulin, should be given as prescribed (30 units). Glargine cannot be mixed with regular insulin in the same syringe due to differing pH levels, so separate injections are required.
The parents of a 2 year-old child report that he has been holding his breath whenever he has temper tantrums. What is the best action by the nurse?
- A. Teach the parents how to perform cardiopulmonary resuscitation
- B. Recommend that the parents give in when he holds his breath to prevent anoxia
- C. Advise the parents to ignore breath holding because breathing will begin as a reflex
- D. Instruct the parents on how to reason with the child about possible harmful effects
Correct Answer: C
Rationale: Advise the parents to ignore breath holding because breathing will begin as a reflex. Breath-holding is benign and self-resolving in toddlers.
A client with schizophrenia is ready to begin participating in therapeutic activities. The nurse should suggest that the client:
- A. Participate on the unit softball team
- B. Attend a class on psychotropic medication
- C. Participate in art activities with three other clients
- D. Watch TV in the unit day room
Correct Answer: C
Rationale: Art activities with a small group provide a structured, low-stress environment suitable for a client with schizophrenia, promoting social interaction without overwhelming them.
A mother has brought her 9-month-old baby to the physician's office for a well baby visit. Based on knowledge of normal growth and development, the nurse would expect that the ability the child has acquired most recently is which of the following?
- A. Sitting up unsupported
- B. Rolling over without help
- C. Holding head up without assistance
- D. Smiling in response to a familiar face
Correct Answer: A
Rationale: By 9 months, sitting unsupported is a recently acquired milestone, typically achieved around 6-8 months, following earlier skills like rolling over and head control.