Nokea
A client with type 1 diabetes has a prescription for 30 units of insulin glargine at bedtime. Fingerstick blood glucose measurements are prescribed before meals and at bedtime with regular insulin based on a sliding scale. At 9 PM, the client's blood glucose measurement is 180 mg/dL (10.0 mmol/L). What action should the nurse take?
- A. Administer 30 units of glargine; give the client a snack, then administer 2 units of regular insulin
- B. Administer 30 units of glargine and 2 units of regular insulin in 2 different injections
- C. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the glargine first
- D. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the regular insulin first
Correct Answer: B
Rationale: The sliding scale indicates 2 units of regular insulin for a glucose of 180 mg/dL. Glargine, a long-acting insulin, should be given as prescribed (30 units). Glargine cannot be mixed with regular insulin in the same syringe due to differing pH levels, so separate injections are required.
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An older adult is diagnosed with open-angle glaucoma. Which comment by the client indicates understanding of the management of the condition?
- A. I will take the eye drops every day.'
- B. I hope the medicine works and I am cured soon.'
- C. My wife is worried that I may give her glaucoma.'
- D. How long will it be before I need surgery?'
Correct Answer: A
Rationale: Daily eye drops control intraocular pressure in open-angle glaucoma, a chronic condition, indicating understanding, unlike expecting a cure, contagiousness, or immediate surgery.
A 2-month-old recently diagnosed with developmental dysplasia of the hip is beginning treatment with a Pavlik harness. Which instructions should the nurse reinforce to the parents? Select all that apply.
- A. Apply lotion under the straps to protect the skin.
- B. Dress the child in a shirt and knee socks under the straps.
- C. Lightly massage the skin under the straps daily.
- D. Place the diaper under the straps.
- E. Remove the harness during diaper changes.
Correct Answer: B,C,D
Rationale: Shirts and socks under straps prevent chafing, daily massage promotes circulation, and diapers under straps ensure hygiene. Lotion traps moisture, risking irritation. The harness should not be removed, even for diaper changes, to maintain correction.
The nurse is observing a 3-year-old client for expected developmental milestones. It would require follow-up if the client cannot
- A. catch a ball at least 50% of the time
- B. copy a square with a pencil or crayon
- C. eat with a spoon
- D. hop on one foot
Correct Answer: B
Rationale: Copying a square is expected by age 4-5, not 3, indicating a fine motor delay requiring follow-up. Catching a ball, eating with a spoon, and hopping are age-appropriate or slightly advanced for a 3-year-old.
The nurse is caring for a client with Kawasaki disease. Which of the following actions would be a priority for the nurse to take?
- A. Monitor the client for gallop heart sounds and decreased urine output.
- B. Provide a quiet, nonstimulating, restful environment for the client.
- C. Apply cool compresses to the skin of the client's hands and feet.
- D. Offer the client soft foods and adequate amounts of clear liquids.
Correct Answer: B
Rationale: A quiet, restful environment reduces irritability and stress in Kawasaki disease, promoting recovery. Monitoring heart sounds/urine output is secondary, as cardiac complications are less immediate. Cool compresses and soft foods are less critical.
A mother has brought her 9-month-old baby to the physician's office for a well baby visit. Based on knowledge of normal growth and development, the nurse would expect that the ability the child has acquired most recently is which of the following?
- A. Sitting up unsupported
- B. Rolling over without help
- C. Holding head up without assistance
- D. Smiling in response to a familiar face
Correct Answer: A
Rationale: By 9 months, sitting unsupported is a recently acquired milestone, typically achieved around 6-8 months, following earlier skills like rolling over and head control.