Nokea
A diabetic client is taking Lantus insulin for regulation of his blood glucose levels. The nurse should know that this insulin will most likely be administered:
- A. Prior to each meal
- B. At night
- C. Midday
- D. Prior to the evening meal
Correct Answer: B
Rationale: Lantus is a long-acting insulin typically administered at night to provide basal coverage. Options A, C, and D are incorrect for its dosing schedule.
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Which of the following findings distinguishes a hydrocele from an inguinal hernia?
- A. The swelling cannot be reduced and is translucent.
- B. The swelling cannot be reduced and is opaque.
- C. The swelling can be reduced and is translucent.
- D. The swelling can be reduced and is opaque.
Correct Answer: A
Rationale: A hydrocele is non-reducible, translucent swelling due to fluid around the testis, unlike an inguinal hernia, which is often reducible and opaque.
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Leg swelling on the operative side.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-hip replacement requiring immediate evaluation. Options B, C, and D are expected or less concerning: incision pain and leg swelling are normal, and urine output 40 mL/hour is adequate.
A client who has been treated for syphilis.
In preparing discharge plans for a client who has been treated for syphilis, it is MOST important for the community health nurse to include which of the following information?
- A. Practice restraint of sexual activity.
- B. The practice of safe sex.
- C. Information about Planned Parenthood.
- D. Signs of a secondary infection.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not effective in the prevention of transmission of sexually transmitted diseases (2) correct-practice of safe sex, e.g., use of condoms, is primary prevention for transmission of sexually transmitted diseases (3) not as effective in the prevention of transmission of sexually transmitted diseases (4) not as effective in the prevention of transmission of sexually transmitted diseases
An adult is being worked up for a possible duodenal ulcer. The nurse knows that which data, if present, would be most consistent with a duodenal ulcer?
- A. Two hours after his last meal, the client says, 'I need to feed my ulcer.'
- B. The client complains of epigastric pain a half hour after eating.
- C. The client has clay-colored stools.
- D. The client complains of pain beneath the right shoulder blade after eating.
Correct Answer: A
Rationale: Duodenal ulcers typically cause pain 2-3 hours after eating, relieved by food ('feeding the ulcer'), unlike pain immediately after eating (gastric ulcer), clay stools (biliary issues), or shoulder pain (gallbladder).
The nurse’s INITIAL priority when managing a physically assaultive client is to
- A. What is the initial priority when managing a physically assaultive client?
- B. Restrict the client to the room.
- C. Place the client under one-to-one supervision.
- D. Restore the client’s self-control and prevent further loss of control.
- E. Clear the immediate area of other clients to prevent harm.
Correct Answer: C
Rationale: Restoring the client’s self-control is the initial priority to ensure safety and prevent escalation. This involves assessing the situation, using psychological or chemical interventions, and possibly physical control. Room restriction, supervision, or clearing the area are secondary or impractical during rapid escalation.