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A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What type of insulin should the nurse prepare to administer to this client?
- A. Regular insulin
- B. NPH insulin
- C. Lispro insulin
- D. Glargine insulin
Correct Answer: A
Rationale: In a client with a blood glucose level of 600 mg/dL, which indicates severe hyperglycemia or diabetic ketoacidosis, the nurse should prepare to administer regular insulin (A). Regular insulin has a rapid onset of action and is the preferred choice for immediate correction of high blood glucose levels. NPH insulin (B), lispro insulin (C), and glargine insulin (D) are not suitable for the rapid correction of severe hyperglycemia.
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The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light while the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first?
- A. Page the unit manager to address the situation.
- B. Close the demographic screen on the computer.
- C. Instruct the UAP to end the phone call immediately.
- D. Send a UAP into the client's room to relieve the nurse.
Correct Answer: B
Rationale: The charge nurse's first action should be to close the demographic screen on the computer to protect patient confidentiality and prevent unauthorized access to sensitive information. This immediate response addresses the breach of patient privacy and ensures that patient data is secure, setting the right priority in managing the situation.
The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?
- A. She is almost sure to be less able to adapt than before.
- B. It's highly likely that she will recover and return to her pre-illness state.
- C. If you can interest her in something besides religion, it will help her stay well.
- D. Cultural strains contribute to each woman's tendencies for recurrences of depression.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?
- A. Provide the client with a list of reputable Internet sites that answer frequently asked questions about medications.
- B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library.
- C. Reassure the client that information about the medication is included in the written instructions.
- D. Encourage the client to call the clinic nurse or health care provider if any questions arise.
Correct Answer: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the clinic nurse or health care provider if any questions arise. Direct communication with healthcare professionals involved in the client's care is crucial to address any concerns promptly and accurately, ensuring the client's safety and understanding of the prescribed medication.
A Native American individual presents to the clinic with complaints of frequent abdominal cramping and nausea. They state that they have chronic constipation and have not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the healthcare provider to implement?
- A. Evaluate the stool samples for the presence of blood
- B. Assess for the presence of an impaction
- C. Determine which home remedies were used
- D. Obtain a list of prescribed medications
Correct Answer: C
Rationale: It is crucial to determine which home remedies the individual has tried to avoid interactions with prescribed treatments and consider cultural practices that may influence their healthcare choices. Understanding the home remedies used can provide insights into the individual's health beliefs, preferences, and potential interactions with conventional treatments, allowing for a more holistic approach to their care.
Ten minutes after signing an operative permit for a fractured hip, an older client states, 'The aliens will be coming to get me soon!' and falls asleep. Which action should the nurse implement next?
- A. Make the client comfortable and allow the client to sleep.
- B. Assess the client's neurologic status.
- C. Notify the surgeon about the comment.
- D. Ask the client's family to co-sign the operative permit.
Correct Answer: B
Rationale: The nurse should assess the client's neurologic status next. The client's statement about aliens and subsequent falling asleep could be indicative of a potential neurological issue such as confusion or altered mental status. It is essential to assess the client's neurological status to determine the underlying cause of the client's statement and behavior. This assessment will help the nurse identify any potential cognitive impairment or neurological deficits that may need immediate attention, ensuring the client's safety and well-being. Notifying the surgeon or involving the client's family can be considered later, but the priority is to assess the client's neurologic status to address any immediate concerns.