Nokea
A client post-hemodialysis reports dizziness. The nurse should:
- A. Check blood pressure.
- B. Administer fluids.
- C. Encourage eating.
- D. Increase dialysis time.
Correct Answer: A
Rationale: Dizziness may indicate hypotension, a common post-dialysis issue.
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A client who is scheduled for an ileostomy has an order for oral neomycin (Mycifradin) to be administered before surgery. The intended outcome of administering oral neomycin before surgery is to:
- A. Prevent postoperative bladder infection.
- B. Reduce the number of intestinal bacteria.
- C. Decrease the potential for postoperative hypostatic pneumonia.
- D. Increase the body's immunologic response to the stressors of surgery.
Correct Answer: B
Rationale: Oral neomycin is administered preoperatively to reduce intestinal bacteria, decreasing the risk of infection during bowel surgery. It does not target bladder infections, pneumonia, or immune response directly. CN: Pharmacological and parenteral therapies; CL: Apply
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.
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.
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.
The surgical floor receives a new postoperative client from the postanesthesia care unit. Assessment reveals that the client has a patent airway and stable vital signs. The nurse should next:
- A. Check the dressing for signs of bleeding.
- B. Empty any peri-incisional drains.
- C. Assess the client's pain level.
- D. Assess the client's bladder.
Correct Answer: C
Rationale: After confirming airway and vital signs, assessing pain level is the next priority, as uncontrolled pain can affect recovery and complicate other assessments or interventions.