Nokea
A client with type 1 diabetes has a prescription for 20 units of NPH insulin daily at 7:30 AM and regular insulin before meals, based on a sliding scale. At 7:00 AM, the client's blood glucose level is 220 mg/dL (12.2 mmol/L), and the client's breakfast tray has arrived. What action should the nurse take?
- A. Administer 20 units of NPH insulin now and then 6 units of regular insulin after the morning meal
- B. Administer 26 units of insulin: 20 units of NPH insulin and 6 units of regular insulin in 2 separate injections
- C. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the NPH into the syringe first
- D. Administer 26 units of insulin: 20 units of NPH mixed with 6 units of regular insulin in the same syringe, drawing up the regular insulin first
Correct Answer: D
Rationale: Regular insulin is drawn up first to prevent NPH contamination, and both can be mixed in one syringe for a blood glucose of 220 mg/dL, assuming a sliding scale of 6 units. Administering after the meal or using separate injections is incorrect.
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The oncoming nurse is receiving report on 4 clients. Which should be the priority assessment?
- A. Client who had a carotid endarterectomy that day with a blood pressure of 160/88 mm Hg
- B. Client who is 1 day post bowel resection with absent bowel sounds
- C. Client with a pulse of 109/min who has a history of atrial fibrillation
- D. Client with pancreatitis whose total parenteral nutrition is almost finished
Correct Answer: A
Rationale: Elevated blood pressure (160/88 mm Hg) post-carotid endarterectomy risks hematoma or stroke, making it the priority. Other conditions are less urgent.
A 19-year-old primigravida is admitted for observation due to a sudden increase in blood pressure. The doctor suspects a diagnosis of pregnancy-induced hypertension. Which of the following is considered a significant factor in the development of pregnancy-induced hypertension?
- A. Maternal age
- B. Nutritional status of mother
- C. Pre-pregnant weight
- D. History of hypertension
Correct Answer: D
Rationale: A history of hypertension is a significant risk factor for developing pregnancy-induced hypertension (preeclampsia), as it indicates a predisposition to vascular issues.
The nurses on a unit are planning for stoma care for clients who have a stoma for fecal diversion. Which stomal diversion poses the highest risk for skin breakdown?
- A. Ileostomy
- B. Transverse colostomy
- C. Ileal conduit
- D. Sigmoid colostomy
Correct Answer: A
Rationale: Ileostomy output contains caustic gastric and enzymatic agents that can denude skin quickly.
A 6 year-old female is diagnosed with recurrent urinary tract infections (UTIs). Which one of the following instructions would be best for the nurse to tell the caregiver?
- A. Increase bladder tone by delaying voiding
- B. When laundering clothing, rinse several times
- C. Use plain water for the bath, shampooing hair last
- D. Have the child use antibacterial soaps while bathing
Correct Answer: C
Rationale: Use plain water for the bath, shampooing hair last. Hair should be shampooed last with a rinsing of plain water over the genital area. The oils in soaps and bubble bath can cause irritation, which may lead to UTIs in young girls.
An adult asks the nurse about blood types. Which information should the nurse plan to include when replying?
- A. Blood typing is not always accurate.
- B. A person cannot receive a factor that he/she does not have.
- C. The universal donor is AB negative.
- D. A person who is O positive can donate blood to anyone.
Correct Answer: B
Rationale: A person cannot receive blood with antigens (factors) they lack, as it causes an immune reaction. Blood typing is accurate, O negative is the universal donor, and O positive can only donate to Rh-positive types.