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A client with type 1 diabetes mellitus is being taught self-administration of insulin by a nurse. Which of the following instructions should the nurse include?
- A. Inject air into the vial before withdrawing the insulin.
- B. Draw up the short-acting insulin first, then the long-acting insulin.
- C. Store unopened insulin vials in the freezer.
- D. Rotate injection sites within the same anatomical region.
Correct Answer: D
Rationale: The correct instruction the nurse should include is to rotate injection sites within the same anatomical region. This practice helps reduce the risk of lipodystrophy, a condition characterized by fatty tissue changes due to repeated insulin injections in the same spot. By rotating sites, the client ensures better insulin absorption and prevents localized skin changes. Injecting air into the vial before withdrawing insulin (Choice A) is unnecessary and not recommended. Drawing up short-acting insulin before long-acting insulin (Choice B) is not a standard practice and can lead to errors in dosing. Storing unopened insulin vials in the freezer (Choice C) is incorrect as insulin should be stored in the refrigerator, not the freezer, to maintain its effectiveness.
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A nurse is assessing a client who has pericarditis. Which of the following findings is the priority?
- A. Paradoxical pulse
- B. Dependent edema
- C. Pericardial friction rub
- D. Substernal chest pain
Correct Answer: A
Rationale: In a client with pericarditis, the priority finding is a paradoxical pulse. This is a crucial sign of cardiac tamponade, a life-threatening complication of pericarditis where fluid accumulates in the pericardial sac, causing compression of the heart. A paradoxical pulse is an exaggerated decrease in systolic blood pressure (>10 mmHg) during inspiration. Prompt recognition and intervention are essential to prevent hemodynamic instability and cardiac arrest. Dependent edema (choice B) is not typically associated with pericarditis. Pericardial friction rub (choice C) is a common finding in pericarditis but does not indicate the urgency of intervention as a paradoxical pulse. Substernal chest pain (choice D) is a classic symptom of pericarditis but is not as critical as a paradoxical pulse in the context of assessing for complications.
A nurse is caring for a client who is receiving continuous enteral feeding through a nasogastric tube. Which of the following actions should the nurse take to prevent aspiration?
- A. Flush the tube with 30 mL of water every 4 hours.
- B. Position the client on the left side during feedings.
- C. Elevate the head of the bed to 45 degrees during feedings.
- D. Check gastric residual every 2 hours.
Correct Answer: C
Rationale: To prevent aspiration in clients receiving continuous enteral feedings, the nurse should elevate the head of the bed to 45 degrees. This position helps reduce the risk of regurgitation and aspiration. Flushing the tube with water every 4 hours (Choice A) is important for maintaining tube patency but does not directly prevent aspiration. Positioning the client on the left side during feedings (Choice B) is not specifically related to preventing aspiration in this context. Checking gastric residual every 2 hours (Choice D) is important to assess feeding tolerance but does not directly prevent aspiration.
A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse expect?
- A. Barrel-shaped chest
- B. Bradycardia
- C. Increased respiratory rate
- D. Tracheal deviation
Correct Answer: C
Rationale: Corrected Rationale: An increased respiratory rate is a common finding in clients with ARDS as the body attempts to compensate for impaired gas exchange. Barrel-shaped chest (Choice A) is associated with conditions like COPD, not ARDS. Bradycardia (Choice B) is unlikely in ARDS due to the body's compensatory mechanisms to improve oxygenation. Tracheal deviation (Choice D) is not typically seen in ARDS and is more suggestive of other respiratory conditions.
A client at 10 weeks of gestation reports frequent nausea and vomiting. Which of the following instructions should the nurse include?
- A. Eat high-protein foods.
- B. Lie down after meals.
- C. Drink water with meals.
- D. Eat dry carbohydrates before getting out of bed.
Correct Answer: D
Rationale: During early pregnancy, nausea and vomiting are common. Instructing the client to eat dry carbohydrates like crackers before getting out of bed can help alleviate these symptoms. This recommendation helps prevent an empty stomach, which can worsen nausea. High-protein foods (Choice A) may be harder to digest and could exacerbate nausea. Lying down after meals (Choice B) may increase gastric reflux and worsen symptoms. Drinking water with meals (Choice C) may make the client feel fuller, potentially worsening nausea.
A client with schizophrenia is beginning therapy with clozapine. Which statement indicates a need for further teaching?
- A. I will need to have my blood work checked regularly while taking clozapine.
- B. I understand that clozapine may cause me to gain weight.
- C. I should report any signs of a fever while taking clozapine.
- D. I should discontinue clozapine once my symptoms improve.
Correct Answer: D
Rationale: The correct answer is D because clients should continue taking clozapine even if their symptoms improve. Abruptly discontinuing the medication can lead to relapse. Choices A, B, and C are all correct statements regarding clozapine therapy. Regular blood work monitoring is necessary due to potential side effects, weight gain is a common side effect of clozapine, and reporting signs of fever is important as it can indicate a serious side effect of clozapine.