Nokea
A nurse is caring for a client who has a prescription for NPH insulin 10 units and regular insulin 15 units subcutaneously. After injecting 10 units of air into the NPH insulin vial, which of the following actions should the nurse take next?
- A. Verify the dosage with another nurse.
- B. Place the cap over the needle.
- C. Withdraw 10 units of NPH insulin.
- D. Inject 15 units of air into the regular insulin vial.
Correct Answer: D
Rationale: Injecting air into the regular insulin vial follows the sequence for mixing insulins (air into NPH, air into regular, withdraw regular, then NPH), preventing contamination and ensuring accurate dosing.
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A nurse is caring for a client who is postoperative following a cholecystectomy. Which of the following actions should the nurse take to promote comfort?
- A. Encourage the client to ambulate every 2 hr.
- B. Offer the client a high-fat meal.
- C. Apply a heating pad to the client's abdomen.
- D. Provide the client with a pillow to splint the incision during coughing.
Correct Answer: D
Rationale: Splinting the incision with a pillow reduces pain during coughing. Ambulation aids recovery but isn't comfort-focused, high-fat meals are avoided, and heating pads risk complications.
A nurse is caring for a client who is receiving a continuous IV infusion. The nurse notes that the skin around the catheter's insertion site is edematous and cool. Which of the following actions should the nurse take first?
- A. Elevate the arm.
- B. Document the infiltration.
- C. Stop the infusion.
- D. Apply a warm compress.
Correct Answer: C
Rationale: Stopping the infusion is the priority to prevent further fluid infiltration, which can cause tissue damage. Elevation, documentation, and compresses follow after halting the infusion.
A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should take this medication in the morning.
- B. I might need to have my liver function checked.
- C. I can stop taking this medication if my cholesterol improves.
- D. I should avoid drinking alcohol while taking this medication.
Correct Answer: B,D
Rationale: Atorvastatin requires liver monitoring due to hepatotoxicity risk and alcohol avoidance to reduce liver strain. It's taken at night, and stopping needs provider input.
A nurse is caring for a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate. Which of the following actions should the nurse take?
- A. Monitor the client's urine output every 4 hr.
- B. Irrigate the catheter with sterile water every 2 hr.
- C. Check the catheter tubing for blood clots.
- D. Administer an antibiotic prophylactically.
Correct Answer: C
Rationale: Checking for clots ensures catheter patency, critical for irrigation. Output monitoring is secondary, manual irrigation isn't routine, and antibiotics depend on orders.
A nurse is reinforcing teaching with a client who has a new prescription for venlafaxine. Which of the following statements should the nurse include?
- A. You should take this medication with food.
- B. You might experience headaches while taking this medication.
- C. You need to avoid caffeine while taking this medication.
- D. You can expect symptom relief within 24 hours.
Correct Answer: B
Rationale: Venlafaxine can cause headaches, a common side effect. Food enhances absorption, caffeine isn't restricted, and relief takes weeks.