Nokea
A nurse administers subcutaneous NPH insulin at 0700 to a child who has diabetes. At which of the following times should the nurse observe for hypoglycemia caused by the onset of the medication?
- A. 715
- B. 730
- C. 1200
- D. 900
Correct Answer: D
Rationale: NPH insulin onset is 1-2 hours; 0900 (2 hours post-0700) is when hypoglycemia may begin.
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A nurse is reinforcing teaching with a client who is scheduled for abdominal surgery about coughing and deep breathing. Which of the following statements should the nurse make?
- A. Inhale through your mouth when deep breathing.
- B. Cough and deep breath every 4 hours.
- C. Lie supine to cough and deep breath.
- D. Splint your incision with a pillow when coughing.
Correct Answer: D
Rationale: Splinting the incision with a pillow reduces pain and supports the surgical site during coughing, enhancing effectiveness post-surgery.
A nurse is assisting with the care of a client who arrives at the emergency department after an industrial explosion. The nurse inspects the wound on the client's leg and finds torn skin tissue underneath. The nurse should report this as which of the following types of wounds?
- A. Contusion
- B. Abrasion
- C. Laceration
- D. Puncture
Correct Answer: C
Rationale: Laceration involves torn skin with irregular edges, matching the description of torn tissue from an explosion.
A nurse is assisting with teaching a client who is on a soft diet. Which of the following foods should the nurse include in the teaching?
- A. Ground beef
- B. Raw vegetables
- C. Fruit with the skin
- D. High-fiber cereals
Correct Answer: A
Rationale: Ground beef is soft and easy to chew, suitable for a soft diet.
A nurse is collecting data on a client who has a stage 2 pressure injury. Which of the following findings should the nurse expect?
- A. Partial-thickness skin loss with red tissue in the wound bed.
- B. Intact skin with localized erythema.
- C. Full-thickness skin loss with visible adipose tissue.
- D. Full-thickness skin loss with visible bone.
Correct Answer: A
Rationale: Stage 2 pressure injuries show partial-thickness loss with a red wound bed, indicating damage to epidermis and possibly dermis.
A nurse is caring for a client who has dysphagia. The nurse should monitor the client for which of the following complications?
- A. Pulmonary embolism
- B. Diarrhea
- C. Pneumonia
- D. Pressure injury
Correct Answer: C
Rationale: Pneumonia, especially aspiration pneumonia, is a major risk in dysphagia due to potential inhalation of food or liquids.