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. Inject 15 units of air into the regular insulin vial.
- B. Withdraw 10 units of NPH insulin.
- C. Verify the dosage with another nurse.
- D. Place the cap over the needle.
Correct Answer: A
Rationale: Injecting air into the regular insulin vial next follows the correct sequence for mixing insulins.
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A nurse is assisting with the care of a client who is receiving a spinal epidural to treat a herniated disc. Which of the following findings should the nurse identify as an indicator of unrelieved pain?
- A. Difficulty swallowing
- B. Constipation
- C. Urinary retention
- D. Clenched teeth
Correct Answer: D
Rationale: Clenched teeth indicate ongoing pain despite the epidural.
A nurse is caring for a client who is in bed and begins experiencing a tonic-clonic seizure. Which of the following actions should the nurse take?
- A. Measure the duration of the seizure
- B. Restrain the client's arms and legs to prevent injury
- C. Lower the side rails of the bed when the seizure begins
- D. Insert an oral airway into the client's mouth
Correct Answer: A
Rationale: Measuring duration aids in assessing seizure severity and planning care.
The son of a client who has Alzheimer's disease and mild hypertension.
A nurse is discussing home care concerns with the son of a client who has Alzheimer's disease and mild hypertension. Which of the following responses should the nurse make?
- A. You owe it to your mother to take care of her now that she needs you.
- B. Let me give you some information about respite care for your mother.
- C. I think you should find other family members who could help your mother.
- D. You should think about placing your mother in a long-term care facility.
Correct Answer: B
Rationale: Respite care information supports the caregiver's well-being.
A nurse is performing nasopharyngeal suctioning for an adult client. Which of the following techniques should the nurse use?
- A. Apply suction while inserting the catheter
- B. Apply intermittent suction for 30 seconds
- C. Insert the catheter 10 cm (4 in)
- D. Wait 1 min between suctioning attempts
Correct Answer: D
Rationale: Waiting 1 minute between attempts allows oxygenation and prevents hypoxia.
The client is taking multiple medications and asks about possible interactions.
A nurse is caring for a client who is taking multiple medications and asks about possible interactions. To which of the following members of the interdisciplinary team should the nurse make a referral?
- A. Social worker
- B. Advanced practice nurse
- C. Patient care technician
- D. Psychologist
Correct Answer: B
Rationale: An advanced practice nurse can expertly assess medication interactions.