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A nurse is preparing a client for intradermal tuberculin skin testing (TST). Which of the following statements should the nurse make?
- A. An indurated area of 4 millimeters indicates a positive result.
- B. The injection site will be evaluated within 24 hours.
- C. A positive result does not always indicate active disease.
- D. The test will not be administered if you have had a previous negative result.
Correct Answer: C
Rationale: A positive tuberculin skin test result indicates TB infection but does not necessarily mean active disease, requiring further testing to confirm.
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A nurse is preparing to administer ondansetron 4 mg IM stat. The amount available is ondansetron for injection 2 mg/mL. How many mL should the nurse administer? (Round the answer to the nearest whole number. Use a leading zero if it applies. (Do not use a trailing zero))
Correct Answer: 2 mL
Rationale: 4 mg ÷ 2 mg/mL = 2 mL. The nurse should administer 2 mL.
A nurse is collecting data from a client who has diabetes mellitus. The client is confused, flushed, and has an acetone odor on his breath. The nurse should anticipate a prescription for which of the following types of insulin to treat the client?
- A. Regular.
- B. NPH.
- C. Glargine.
- D. Detemir.
Correct Answer: A
Rationale: Regular insulin is a short-acting insulin used to treat diabetic ketoacidosis (DKA), which is indicated by the client's symptoms of confusion, flushed appearance, and acetone odor on the breath.
A nurse is reinforcing dietary instructions with a client who has episodes of biliary colic from chronic cholecystitis. Which of the following diets should the nurse reinforce in the teaching plan?
- A. A high protein diet.
- B. A high fiber diet.
- C. A low sodium diet.
- D. A low fat diet.
Correct Answer: D
Rationale: A low fat diet is recommended for clients with biliary colic from chronic cholecystitis as it reduces the workload on the gallbladder and decreases the risk of gallstone formation.
A nurse is caring for a client who is scheduled for a blood sampling for a serum creatinine level. The client asks the nurse, "What is the purpose of this test?" Which of the following responses should the nurse give?
- A. This test will inform your provider if you are anemic.
- B. This test will inform your provider if you have an infection.
- C. This test will inform your provider how your kidneys are functioning.
- D. This test will inform your provider if you have a thyroid disorder.
Correct Answer: C
Rationale: A serum creatinine test measures the level of creatinine in the blood, which is an indicator of kidney function. Elevated creatinine levels can indicate impaired kidney function or kidney disease.
An adult client newly diagnosed with type 2 diabetes mellitus asks a nurse to explain how he developed the condition. Which of the following responses should the nurse make?
- A. Your body will continue producing too much insulin without medicine to counteract it.
- B. Your body doesn't process glucose well.
- C. Your body's hemoglobin is not binding to the sugar you consume.
- D. Your body's immune system has destroyed cells in your pancreas.
Correct Answer: B
Rationale: Type 2 diabetes involves insulin resistance, where the body cannot process glucose effectively, leading to elevated blood glucose levels.