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A client with diabetes mellitus has a prescription for Glucotrol XL (glipizide). The client should be instructed to take the medication:
- A. At bedtime
- B. With breakfast
- C. Before lunch
- D. After dinner
Correct Answer: B
Rationale: Taking Glucotrol XL with breakfast aligns with its peak action to control post-meal glucose in diabetes bedtime, pre-lunch, or post-dinner mistime it. Nurses teach this, ensuring glycemic control, vital for managing type 2 diabetes effectively.
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The nurse prepares to administer buccal medication. The medicine should be placed...
- A. On the client's skin
- B. Between the client's cheeks and gums
- C. Under the client's tongue
- D. On the client's conjunctiva
Correct Answer: B
Rationale: Buccal medication is placed between the cheeks and gums for absorption.
The nurse is caring for a client receiving oxygen therapy via a simple face mask. Which nursing intervention is important to prevent skin breakdown?
- A. Changing the position of the mask every 2 hours
- B. Applying a protective barrier cream to the client's face
- C. Padding the pressure points on the client's face with soft material
- D. Encouraging the client to remove the mask intermittently for facial skin care
Correct Answer: C
Rationale: Padding pressure points with soft material (C) prevents skin breakdown from a simple face mask by reducing friction and pressure on the face. Repositioning q2h (A) helps but isn't enough alone. Barrier cream (B) is for moisture, not pressure. Intermittent removal (D) disrupts therapy. Padding, per skin integrity standards, is proactive.
The nurse is caring for a client with a suspected myocardial infarction. Which laboratory value is most specific for confirming the diagnosis?
- A. Troponin I
- B. Creatine kinase (CK)
- C. Myoglobin
- D. Lactic dehydrogenase (LDH)
Correct Answer: A
Rationale: Troponin I is the most specific marker for myocardial infarction, rising within hours and staying elevated for days CK and myoglobin are less specific, LDH is outdated. Nurses monitor this, correlating with ECG and symptoms, aiding rapid diagnosis and treatment.
What is the term used for a high-pitched musical sound in clients during a respiratory assessment?
- A. Crowing
- B. Wheezing
- C. Stridor
- D. Sigh
Correct Answer: B
Rationale: A high-pitched musical sound during breathing is wheezing, caused by air passing through narrowed airways, often due to asthma, allergies, or obstruction. Stridor is a harsh, high-pitched sound from upper airway obstruction, distinct from wheezing's expiratory nature. Crowing resembles a rooster's call, linked to laryngospasm, not a musical tone. A sigh is a deep breath, not pathological. Wheezing's recognition guides interventions like bronchodilators, addressing underlying inflammation or constriction, crucial for restoring normal respiration and preventing hypoxia.
Your assigned client seems to be getting a lot of attention from his mother when he complains of pain. The mother may be encouraging which of the following types of gains?
- A. primary gains
- B. secondary gains
- C. narcissistic gains
- D. egocentric gains
Correct Answer: B
Rationale: Maternal attention for pain suggests secondary gains external benefits beyond primary relief or other gains. Nurses address this in behavioral pain management.