Nokea
A client is to receive glargine (Lantus) insulin in addition to a dose of aspart (NovoLog). When the nurse checks the blood glucose level at the bedside, it is greater than 200 mg/dL. How should the nurse administer the insulins?
- A. Put air into the glargine insulin vial, and then air into the aspart insulin vial, and draw up the correct dose of aspart insulin first.
- B. Roll the glargine insulin vial, then roll the aspart insulin vial. Draw up the longer-acting glargine insulin first.
- C. Shake both vials of insulin before drawing up each dose in separate insulin syringes.
- D. Add a little air to the glargine insulin vial and draw up the correct dose in an insulin syringe; then, with a different insulin syringe, put air into the aspart vial and draw up the correct dose.
Correct Answer: D
Rationale: Glargine and aspart insulins cannot be mixed. They should be drawn up in separate syringes to maintain their distinct actions (long-acting vs. rapid-acting). Shaking or rolling is inappropriate for glargine, which is clear.
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The best method to remove cerumen from a client's ear involves:
- A. Inserting a cotton-tipped applicator into the external canal.
- B. Irrigating the ear gently.
- C. Using aural suction.
- D. Using a cerumen curette.
Correct Answer: B
Rationale: Gentle irrigation with warm water or saline is the safest and most effective method to remove cerumen, avoiding trauma to the ear canal or eardrum.
A priority goal for the hospitalized client who 2 days earlier had a total laryngectomy with creation of a new tracheostomy would be to:
- A. Decrease secretions.
- B. Instruct the client in caring for the tracheostomy.
- C. Relieve anxiety related to the tracheostomy.
- D. Maintain a patent airway.
Correct Answer: D
Rationale: Maintaining a patent airway is the priority goal post-laryngectomy with a new tracheostomy to ensure adequate oxygenation and prevent respiratory distress.
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.
The nurse is conducting a focused assess of the gastrointestinal system of a client with a burn injury. The nurse should assess the client for:
- A. Paralytic ileus.
- B. Gastric distention.
- C. Hiatal hernia.
- D. Curling's ulcer.
Correct Answer: D
Rationale: Burn injuries increase stress and metabolic demand, predisposing clients to Curling's ulcer, a stress-related gastric ulcer, due to reduced mucosal protection.
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
- A. Head trauma.
- B. Electrolyte imbalance.
- C. Congenital defect.
- D. Epilepsy.
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.