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A client with diabetes mellitus must learn how to self-administer insulin. The physician has prescribed 10 U of U- 100 regular insulin and 35 U of 100-U isophane insulin suspension (NPH) to be taken before breakfast. When teaching the client how to select and rotate insulin injection sites, the nurse should provide which instruction?
- A. "Inject insulin into healthy tissue with large blood vessels and nerves."
- B. "Rotate injection sites within the same anatomic region, not among different regions."
- C. "Administer insulin into areas of scar tissue or hypotrophy whenever possible."
- D. "Administer insulin into sites above muscles that you plan to exercise heavily later that day."
Correct Answer: B
Rationale: The nurse should instruct the client to rotate injection sites within the same anatomic region, not among different regions. Proper rotation of injection sites helps prevent lipodystrophy (changes in fat tissue) and ensures consistent absorption of insulin. By rotating sites within the same region, the client can minimize the risk of developing localized skin complications. Additionally, rotating sites helps to ensure that the insulin is absorbed consistently, leading to more predictable blood glucose control. It is important to avoid injecting into areas of scar tissue, hypotrophy, large blood vessels, or nerves, as these can affect the absorption of insulin and may lead to inconsistent blood glucose levels.
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Which nursing action is most appropriate for the weak patient with osteoporosis?
- A. Maintain bedrest
- B. Ambulate with assistance
- C. Encourage fluids
- D. Provide a high-protein diet
Correct Answer: B
Rationale: For a weak patient with osteoporosis, it is important to promote mobility and weight-bearing activities to help maintain bone strength and prevent further bone loss. Ambulating with assistance can help improve muscle strength and balance, reducing the risk of falls and fractures. Maintaining bedrest can lead to further weakness and bone loss, so it is not the most appropriate action in this case. Encouraging fluids and providing a high-protein diet are important for overall health and healing but might not directly address the specific needs of a weak patient with osteoporosis.
The parent of a 2-week-old infant, exclusively breastfed, asks the nurse if fluoride supplements are needed. What is the nurse's best response?
- A. "She needs to begin taking them now."
- B. "They are not needed if you drink fluoridated water."
- C. "She may need to begin taking them at age 4 months."
- D. "She can have infant cereal mixed with fluoridated water instead of supplements."
Correct Answer: B
Rationale: The nurse's best response to the parent of a 2-week-old infant, exclusively breastfed, regarding the need for fluoride supplements is that they are not needed if the infant is already drinking fluoridated water. Fluoride supplements are typically recommended for infants who are not receiving enough fluoride through their water source. Breast milk itself does not contain a significant amount of fluoride, but if the family's water supply is fluoridated, the infant will likely receive an adequate amount of fluoride without the need for supplements. It is important for the parent to verify the fluoride content of their water supply with their local water utility to ensure the infant is receiving the appropriate amount of fluoride for dental health.
Which should the nurse recommend for the diet of a child with chronic renal failure?
- A. High in protein
- B. Low in vitamin D
- C. Low in phosphorus
- D. Supplemented with vitamins A, E, and K
Correct Answer: C
Rationale: For a child with chronic renal failure, it is important to recommend a diet that is low in phosphorus. In chronic renal failure, the kidneys have difficulty filtering phosphorus from the blood, leading to high levels of phosphorus in the body. High phosphorus levels can contribute to bone problems and other complications in renal failure patients. By recommending a diet low in phosphorus, the nurse can help manage the child's condition and reduce the risk of further complications. It is also important to monitor other electrolyte levels such as calcium, potassium, and sodium, and adjust the diet accordingly to maintain proper balance.
A school nurse observes a child, with a peanut allergy, in obvious distress, wheezing and cyanotic, after ingestion of some trail mix containing peanuts. Place the interventions the nurse should implement in order of the highest priority to the lowest priority. Provide answer using lowercase letters separated by commas (e.g., a, b, c, d).
- A. Call Jason's parents and notify them of the situation.
- B. Call Jason's family practitioner to obtain further orders for medication.
- C. Promptly administer an intramuscular dose of epinephrine. TestBankWorld.org
- D. Call 911 and wait for the emergency response personnel to arrive.
Correct Answer: c
Rationale: The highest priority intervention in this situation is 'C': Promptly administer an intramuscular dose of epinephrine. Epinephrine is The first-line treatment for anaphylaxis, which is a severe allergic reaction that can be life-threatening. Administering Epinephrine as soon as possible can help reverse The symptoms and stabilize The child.
Which of the ff symptoms is observed in the client with Right Sided Heart Failure?
- A. Dependent pitting edema
- B. Orthopnea
- C. Exertional dyspnea
- D. Hemoptysis CARING FOR CLIENTS UNDERGOING CARDIOVASCULAR SURGERY
Correct Answer: A
Rationale: Right-sided heart failure is characterized by the inability of the right side of the heart to pump blood effectively, leading to fluid accumulation in the systemic venous system. This fluid overload typically manifests as signs of congestion in the peripheral tissues. Dependent pitting edema is a classic symptom of right-sided heart failure, where swelling is noted in the lower extremities and sacral area, worsening later in the day due to the effects of gravity. Orthopnea (B) and exertional dyspnea (C) are more indicative of left-sided heart failure, where congestion occurs in the pulmonary system. Hemoptysis (D) refers to coughing up blood and is not a classic symptom of heart failure but may be seen in conditions such as pulmonary embolism or infection.