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A client is scheduled for a cardiac catheterization, and the nurse teaches him about the procedure. What statements, if made by the client, would indicate to the nurse that he understands the teaching?
- A. I'm going to feel cold during the procedure.
- B. I can get up and walk to the bathroom immediately after the procedure.
- C. The nurse will be checking my foot pulses after the procedure.
- D. I won't be able to eat for 24 hours before the procedure.
Correct Answer: C
Rationale: peripheral pulses checked every 15 min for 1 h, then every 30 min for 2 h, then every 4 h
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The nurse is teaching a client with type 1 diabetes about insulin administration. Which of the following statements by the client indicates a need for further teaching?
- A. I should rotate injection sites to prevent tissue damage.
- B. I should store my insulin in the refrigerator.
- C. I should check my blood sugar before giving insulin.
- D. I should inject insulin into my thigh if I’m going to exercise.
Correct Answer: D
Rationale: Injecting insulin into the thigh before exercise can increase absorption due to muscle activity, risking hypoglycemia. The abdomen is preferred for consistent absorption. Options A, B, and C are correct: rotation prevents lipodystrophy, refrigeration preserves insulin, and checking blood sugar ensures proper dosing.
A client has an order for furosemide (Lasix) 40 mg IV push via a heparin lock. Which of the following nursing actions would be MOST appropriate?
- A. Use a 16- to 18-gauge 1-in needle for administration.
- B. Administer the medication over one to two minutes.
- C. One cc of 1:1,000 heparin flush should be administered before the medication.
- D. A primary IV should be started prior to medication administration.
Correct Answer: B
Rationale: furosemide (Lasix) given IV push should be administered slowly over one to two minutes
An 8-year-old boy is brought to the physician’s office by his mother. The mother is concerned because the boy has a fever, vomited twice, and slept all day yesterday with the curtains closed. The boy complains of headache, nausea, and has a temperature of 103°F (39.3°C). The nurse observes the boy has a petechial rash on the trunk of his body. Which of the following assessments would be MOST important for the nurse to perform?
- A. Grasp the child’s hands and ask him to squeeze the nurse’s hands.
- B. Stroke the plantar surface of the child’s foot with a reflex hammer.
- C. Gently flex the child’s head and neck onto the chest.
- D. Have the child stand with his eyes closed, his arms at his sides, and his feet and knees close together.
Correct Answer: C
Rationale: Fever, headache, nausea, and petechial rash suggest meningitis; flexing the neck (Brudzinski’s sign) assesses meningeal irritation, a priority. Options A, B, and D are less relevant: hand squeeze is nonspecific, Babinski’s sign is not indicated, and Romberg’s sign assesses balance.
When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse?
- A. Short-term memory is more efficient than long-term memory.
- B. The stress of an unfamiliar environment may cause confusion.
- C. A decline in mental status is a normal part of aging.
- D. Learning ability is reduced during hospitalization of the elderly client.
Correct Answer: B
Rationale: stress of an unfamiliar situation or environment may lead to confusion in elderly clients
The nurse is caring for a client with a history of type 2 diabetes who is receiving glipizide (Glucotrol) 5 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and shakiness.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a serious glipizide side effect. Options A, C, and D are less urgent.