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A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse about insulin administration. Which of the following instructions should the nurse include?
- A. Store unopened vials of insulin in the refrigerator, not the freezer.
- B. Rotate injection sites within the same region to prevent tissue damage.
- C. Administer insulin at a 90-degree angle for subcutaneous injections.
- D. Avoid massaging the injection site after administering insulin.
Correct Answer: B
Rationale: The correct answer is to rotate injection sites within the same region to prevent tissue damage. By rotating sites, the client can prevent lipodystrophy, which is a condition characterized by the loss or change in body fat at the site of repeated injections. This practice also helps to ensure proper insulin absorption. Storing unopened vials of insulin in the refrigerator (Choice A) is correct, not in the freezer, as freezing can damage the insulin. Administering insulin at a 90-degree angle (Choice C) is more appropriate for subcutaneous injections, while a 45-degree angle is used for intramuscular injections. Massaging the injection site after administering insulin (Choice D) is not recommended as it can affect insulin absorption rates.
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A client who has a new prescription for lithium is receiving teaching from a nurse. Which of the following statements by the client indicates an understanding of the teaching?
- A. ''I will avoid eating foods that contain tyramine.''
- B. ''I should increase my salt intake while taking this medication.''
- C. ''I should drink at least 2 liters of water each day while taking this medication.''
- D. ''I should avoid consuming caffeinated beverages while taking this medication.''
Correct Answer: C
Rationale: The correct answer is C. Drinking at least 2 liters of water daily is crucial for clients taking lithium to prevent dehydration and lithium toxicity. Lithium is a salt, so it's important for clients to maintain adequate hydration. Option A is incorrect because lithium does not interact with tyramine-containing foods. Option B is incorrect because increasing salt intake is not necessary and can actually exacerbate lithium toxicity. Option D is incorrect because avoiding caffeinated beverages is not a priority teaching point for clients taking lithium.
A client with schizophrenia is experiencing delusions. Which of the following interventions should the nurse implement?
- A. Tell the client that their delusions are not real
- B. Encourage the client to explore the meaning behind their delusions
- C. Focus on the client's feelings rather than the delusions
- D. Challenge the client's delusions directly
Correct Answer: C
Rationale: In caring for a client with schizophrenia experiencing delusions, it is essential to focus on the client's feelings rather than directly addressing or challenging the delusions. By focusing on the client's emotions, the nurse can build trust and rapport without reinforcing the delusions. Choice A is incorrect because directly telling the client that their delusions are not real may lead to confrontation or mistrust. Choice B is incorrect as encouraging exploration of the delusions may further validate them. Choice D is incorrect because challenging the client's delusions can escalate the situation and damage the therapeutic relationship.
A nurse is caring for a client who has deep-vein thrombosis (DVT) and is receiving heparin therapy. Which of the following laboratory values indicates that the client's heparin therapy is effective?
- A. aPTT 75 seconds.
- B. INR 1.2.
- C. Hemoglobin 10 g/dL.
- D. Fibrinogen level 350 mg/dL.
Correct Answer: A
Rationale: An aPTT of 75 seconds indicates that heparin therapy is within the therapeutic range for a client with DVT. The activated partial thromboplastin time (aPTT) is used to monitor heparin therapy's effectiveness. Choice B, INR 1.2, is not the correct answer because INR is used to monitor the effectiveness of warfarin, a different anticoagulant, not heparin. Choice C, Hemoglobin 10 g/dL, is not a measure of heparin therapy effectiveness. Choice D, Fibrinogen level 350 mg/dL, is not a specific indicator of heparin therapy effectiveness for DVT.
A nurse is reviewing the laboratory report of a client who has been receiving lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect?
- A. Withhold the next dose.
- B. Increase the dosage.
- C. Discontinue the medication.
- D. Administer the medication.
Correct Answer: D
Rationale: Administering the medication is appropriate for a stable lithium level of 0.8 mEq/L. A level of 0.8 mEq/L falls within the therapeutic range for lithium, indicating that the client is receiving an adequate dose to maintain therapeutic effects. Withholding the next dose, increasing the dosage, or discontinuing the medication would not be indicated at this lithium level as it is within the desired range for therapeutic benefit. Therefore, the correct action would be to continue administering the medication to ensure the client maintains the therapeutic level of lithium.
A nurse is providing discharge teaching to a client who has a new prescription for nitroglycerin sublingual tablets. Which of the following statements should the nurse include?
- A. Take the medication with food to reduce stomach upset.
- B. Store the medication in a cool, dry place.
- C. Take one tablet every 5 minutes until the pain is relieved, up to three doses.
- D. This medication may cause drowsiness.
Correct Answer: C
Rationale: The correct answer is to instruct the client to take one nitroglycerin sublingual tablet every 5 minutes until the pain is relieved, up to three doses. This dosing regimen is essential for managing angina attacks effectively. Choice A is incorrect because nitroglycerin sublingual tablets should be placed under the tongue for rapid absorption, not taken with food. Choice B is incorrect because nitroglycerin tablets should be stored in their original container at room temperature, away from moisture and heat. Choice D is incorrect because nitroglycerin typically does not cause drowsiness as a side effect.