Nokea
A newly diagnosed diabetic is learning to administer her injections of NPH and regular insulin. Which statement indicates that the client understands the nurse's teaching regarding proper insulin administration?
- A. I will administer the NPH and regular insulin in two separate injections.
- B. I will withdraw the dose of regular insulin before withdrawing the NPH insulin.
- C. It does not matter which insulin is withdrawn first as long as the amount is correct.
- D. I will withdraw the dose of NPH insulin before withdrawing the regular insulin.
Correct Answer: B
Rationale: When mixing NPH and regular insulin, regular insulin (clear) should be withdrawn first to avoid contaminating it with NPH (cloudy). Separate injections are not standard. Order matters (C is incorrect). Withdrawing NPH first risks contamination.
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The nurse is aware that which of the following assessments would be indicative of hypocalcemia?
- A. Constipation.
- B. Depressed reflexes.
- C. Decreased muscle strength.
- D. Positive Trousseau's sign.
Correct Answer: D
Rationale: positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia
The client is being admitted for surgery. During the admission assessment, the client states that she usually has 8 to 10 alcoholic drinks a day. How should the nurse reply?
- A. What type of alcohol do you drink?
- B. How long have you been drinking alcohol?
- C. When was your last drink?
- D. Why do you drink so much?
Correct Answer: C
Rationale: Admitting to 8 to 10 alcoholic drinks a day is suggestive of alcoholism. It is important to know when the client last had a drink of alcohol in order to anticipate the onset of withdrawal symptoms. The type of alcohol the client drinks, how long the client has been drinking, and why the client drinks are not the key issues. The key issue is when to anticipate withdrawal symptoms.
The nurse is teaching a client with newly diagnosed diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak feet in hot water daily.
- B. Apply lotion between the toes.
- C. Trim toenails with rounded edges.
- D. Inspect feet daily for cuts or sores.
Correct Answer: D
Rationale: Daily foot inspection prevents complications like infections in diabetes. Options A, B, and C risk burns, fungal growth, or ingrown nails.
The nurse is caring for a client who is postoperative day 1 after a coronary artery bypass graft (CABG). Which of the following findings would be of GREATest concern to the nurse?
- A. Heart rate of 100 bpm.
- B. Temperature of 100.8°F (38.2°C).
- C. Chest tube drainage of 150 mL/hour.
- D. Blood pressure of 130/80 mmHg.
Correct Answer: C
Rationale: Chest tube drainage of 150 mL/hour is excessive post-CABG, suggesting hemorrhage, requiring immediate evaluation. Options A, B, and D are less concerning: heart rate 100 bpm and temperature 100.8°F are common, and blood pressure 130/80 mmHg is normal.
After a client develops left-sided hemiparesis from a cerebral vascular accident (CVA), there is a decrease in muscle tone.
- A. Which nursing diagnosis is a priority for a client with left-sided hemiparesis post-CVA?
- B. Alteration in mobility related to paralysis.
- C. Alteration in skin integrity related to decrease in tissue oxygenation.
- D. Alteration in skin integrity related to immobility.
- E. Alteration in communication related to decrease in thought processes.
Correct Answer: B
Rationale: Decreased tissue oxygenation from impaired circulation in hemiparesis is the leading cause of skin breakdown, making this the priority nursing diagnosis. Mobility and immobility are concerns, but tissue perfusion is more critical, and communication issues are more relevant to right-sided CVA.