Nokea
A client with type 1 diabetes mellitus is resistant to learning self-injection of insulin. Which of the following statements should the nurse make?
- A. Ask, 'Tell me what I can do to help you overcome your fear of giving yourself injections.'
- B. Instruct, 'You need to learn how to give yourself insulin injections immediately.'
- C. State, 'Insulin injections are important for managing your diabetes, so you must learn them.'
- D. Mention, 'Many people with diabetes manage well with insulin injections.'
Correct Answer: A
Rationale: The correct answer is A. Asking the client what can be done to help overcome the fear of self-injections demonstrates empathy, understanding, and a willingness to support the client in addressing their barriers. This approach facilitates open communication, acknowledges the client's feelings, and involves them in the decision-making process. Choices B and C are authoritarian and may increase resistance in the client by being directive and not considering the client's perspective. Choice D, while positive, does not directly address the client's fear and resistance to self-injections, missing the opportunity to explore the underlying issues.
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When administering an otic medication to an older adult client, which action should the nurse take to ensure that the medication reaches the inner ear?
- A. Press gently on the tragus of the client's ear
- B. Pack a small piece of cotton deep into the client's ear canal
- C. Move the client's auricle down and back toward their head
- D. Tilt the client's head backward for 5 minutes
Correct Answer: A
Rationale: The correct action to ensure that otic medication reaches the inner ear is to press gently on the tragus. The tragus is a small cartilaginous projection in front of the ear canal. Pressing on it helps to straighten the ear canal, allowing the medication to reach the inner ear. Packing cotton or moving the auricle can obstruct the ear canal and prevent proper medication delivery. Tilting the client's head backward is not necessary and may not facilitate the medication reaching the inner ear as effectively as pressing on the tragus.
To ensure the safety of a client receiving a continuous intravenous normal saline infusion, how often should the LPN change the administration set?
- A. Every 4 to 8 hours
- B. Every 12 to 24 hours
- C. Every 24 to 48 hours
- D. Every 72 to 96 hours
Correct Answer: D
Rationale: The correct answer is to change the administration set every 72 to 96 hours. This practice helps reduce the risk of infection by preventing the build-up of bacteria in the tubing. Changing the set too frequently (choices A, B, and C) may increase the chances of contamination and infection without providing additional benefits. Therefore, the LPN should follow the guideline of changing the administration set every 72 to 96 hours to maintain the client's safety during the continuous intravenous normal saline infusion.
The patient diagnosed with athlete's foot (tinea pedis) states that he is relieved because it is only athlete's foot, and it can be treated easily. Which information about this condition should the nurse consider when formulating a response to the patient?
- A. It is contagious with frequent recurrences.
- B. It is most helpful to air-dry feet after bathing.
- C. It is treated with salicylic acid.
- D. It is caused by lice.
Correct Answer: A
Rationale: Athlete's foot, also known as tinea pedis, is a contagious fungal infection that can easily spread to other body parts, particularly the hands. It often recurs if not properly treated, making choice A the correct answer. Choices B and C are incorrect because while it is beneficial to air-dry feet after bathing to prevent moisture buildup, athlete's foot is commonly treated with antifungal medications, not salicylic acid. Choice D is incorrect because athlete's foot is caused by a fungal infection, not lice.
When assessing a client's IV for infiltration, which finding would be unexpected for the nurse?
- A. The area around the infusion site feels warm to the touch.
- B. The infusion site is swollen and cool to the touch.
- C. The infusion line does not flush properly.
- D. There is no blood return in the infusion line.
Correct Answer: A
Rationale: The correct answer is A. Warmth around the infusion site is not an expected finding with infiltration. Infiltration typically presents with swelling and coolness due to the fluid leaking into the surrounding tissue. Choices B, C, and D are incorrect because swelling, coolness, and difficulty flushing the line, as well as lack of blood return, are commonly associated with infiltration.
A client with a prescription for a clear liquid diet is receiving teaching about food choices from a nurse. Which of the following selections by the client indicates an understanding of the teaching?
- A. Gelatin
- B. Whole milk
- C. Cream soups
- D. Orange juice
Correct Answer: A
Rationale: The correct answer is A: Gelatin. Gelatin is suitable for a clear liquid diet because it is transparent and free of solid particles. Clear liquid diets are designed to be easily digested and leave minimal residue in the gastrointestinal tract. Choices B, C, and D are not appropriate for a clear liquid diet. Whole milk, cream soups, and orange juice contain solid particles or pulp, which are not allowed on a clear liquid diet. Whole milk and cream soups are not clear liquids as they contain milk solids and vegetable particles respectively. Orange juice contains pulp, which is not part of a clear liquid diet. It is important for clients to follow dietary restrictions to achieve the intended therapeutic outcomes.