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A diabetic client who takes insulin is being seen by the nurse for a low blood glucose level. Which of the following would be the best choices to begin to raise the blood glucose level? Select all that apply.
- A. One-half cup of orange juice.
- B. One cup of milk.
- C. One ounce of tuna.
- D. One tablespoon of peanut butter.
- E. One piece of bread.
- F. One-half cup of regular soda.
Correct Answer: A, B, E, F
Rationale: Orange juice, milk, bread, and regular soda contain fast-acting carbohydrates to raise blood glucose quickly.
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A client with a history of chronic obstructive pulmonary disease (COPD) is prescribed ipratropium (Atrovent). The nurse should instruct the client to:
- A. Rinse the mouth after inhalation.
- B. Take the medication with meals.
- C. Avoid using the inhaler during an acute attack.
- D. Stop the medication if dizziness occurs.
Correct Answer: A
Rationale: Rinsing the mouth after ipratropium inhalation prevents oral irritation or infection.
The nurse working in the mental health unit is collecting data on a newly admitted client. Which data is a primary type of subjective data collection?
- A. Client complains of a headache.
- B. Client's blood pressure is 145/88.
- C. Family member states that the client got into a fight.
- D. Police officer reports that a disturbance was created by the client.
Correct Answer: A
Rationale: Assessments are conducted by many professionals, including nurses, psychiatrists, social workers, dietitians, and other therapists. Subjective data include information that can be described or verified only by the client or family. The primary source of data is the client. Objective data can be observed or measured. Secondary sources of data may need to be collected if the client is experiencing psychosis, muteness, or catatonia. These sources of data include family, friends, neighbors, police officers, health care workers, and medical records.
A client who is paraplegic cannot feel her lower extremities and has been positioned on her side. The nurse should inspect which of the following areas that is a potential pressure point when the client is in this position?
- A. Sacrum.
- B. Occiput.
- C. Ankles.
- D. Heel.
Correct Answer: C
Rationale: When side-lying, the ankles are a common pressure point due to prolonged contact with the bed. The sacrum, occiput, and heel are more at risk in other positions like supine.
The nurses in the neonatal intensive care unit are not identifying important clinical changes in the clients that need to be documented. The unit director should initiate which of the following actions? Select all that apply.
- A. Identify the problem at a staff meeting without placing blame on any individual or group.
- B. Ask the unit staff to develop a plan that they think will solve this problem.
- C. Ask an experienced nurse to spend time reorienting newer staff members.
- D. Collaborate with the staff development educator to develop a plan.
- E. Ask the neonatologist to give a presentation about assessing newborns.
Correct Answer: A,C,D,E
Rationale: Addressing the issue without blame, involving staff in solutions, reorienting newer staff, collaborating with educators, and arranging expert presentations are all effective strategies to improve documentation.
Which of the following correctly describes Medicaid?
- A. A program designed to assist ill, low-income older adults.
- B. A federal insurance program for pregnant women.
- C. A joint federal-state program for low-income persons.
- D. A program administered by health maintenance organizations.
Correct Answer: C
Rationale: Medicaid is a joint federal-state program providing healthcare coverage for low-income individuals, including children, pregnant women, and the elderly.