Nokea
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin.The client has prescriptions for regular and NPH insulins. Which
of the following statements by the client indicates an understanding of the teaching?
- A. I will draw up the regular insulin into the syringe first.
- B. I will shake the NPH vial vigorously before drawing up the insulin.
- C. I will store prefilled syringes in the refrigerator with the needle pointed downward.
- D. I will insert the needle at a 15-degree angle.
Correct Answer: A
Rationale: Correct Answer: A: I will draw up the regular insulin into the syringe first.
Rationale: Drawing up regular insulin first is crucial for preventing contamination between the two insulins. Regular insulin is a clear solution and should be drawn up first to prevent any cloudiness or contamination from the NPH insulin, which is a cloudy suspension. Drawing up regular insulin first ensures accuracy in dosing and prevents mixing of the two insulins.
Incorrect Choices:
B: Shaking the NPH vial vigorously before drawing up the insulin is incorrect as it can cause bubbles and affect the accuracy of the dose.
C: Storing prefilled syringes in the refrigerator with the needle pointed downward is incorrect as it can lead to leakage or contamination.
D: Inserting the needle at a 15-degree angle is incorrect as insulin injections should be administered at a 90-degree angle for proper absorption.
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A nurse is providing discharge teaching for a client who is receiving treatment for genital herpes. Which of the following statements by the client indicates effectiveness of the teaching?
- A. I should apply antibiotic ointment to the lesions.'
- B. I should use natural skin condoms during sexual intercourse.'
- C. I should expect my lesions to resolve in 6 weeks.'
- D. I should expect to take my medication for 3 weeks.'
Correct Answer: C
Rationale: The correct answer is C: "I should expect my lesions to resolve in 6 weeks." This indicates effectiveness of teaching because it shows the client understands the natural course of genital herpes and the expected timeline for resolution. Choice A is incorrect because antibiotic ointment is not recommended for herpes. Choice B is incorrect because natural skin condoms do not provide adequate protection against herpes. Choice D is incorrect because treatment duration may vary and is not always 3 weeks.
A nurse is providing discharge teaching to a client following a modified left radical mastectomy with breast expander. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will perform strength-building arm exercises using a 15-pound weight.'
- B. I should expect less than 25 mL of secretions per day in the drainage devices.'
- C. I will have to wait 2 months before additional saline can be added to my breast expander.'
- D. I will keep my left arm flexed at the elbow as much as possible.'
Correct Answer: B
Rationale: The correct answer is B: "I should expect less than 25 mL of secretions per day in the drainage devices." This demonstrates an understanding of the need to monitor drainage postoperatively. Excessive drainage can indicate complications like infection or bleeding.
A: Performing strength-building exercises with a 15-pound weight is contraindicated postoperatively as it can strain the surgical site.
C: Waiting 2 months before adding saline to the expander is incorrect. Saline can be added gradually postoperatively.
D: Keeping the left arm flexed at the elbow is not recommended as it can lead to stiffness and limited range of motion.
A nurse is administering furosemide 80 mg PO twice daily to a client who has pulmonary edema. Which of the following assessment findings indicates to the nurse that the medication is effective?
- A. Adventitious breath sounds
- B. Respiratory rate of 24/min
- C. Weight loss of 1.8 kg (4 lb) in the past 24 hr
- D. Elevation in blood pressure
Correct Answer: C
Rationale: The correct answer is C: Weight loss of 1.8 kg (4 lb) in the past 24 hr. Furosemide is a diuretic that helps to reduce fluid retention, so weight loss indicates the medication is effectively reducing pulmonary edema. Adventitious breath sounds indicate respiratory issues, not medication effectiveness. A respiratory rate of 24/min could be within normal range and not necessarily indicative of medication effectiveness. Elevation in blood pressure could indicate a potential adverse effect of furosemide, not effectiveness. Weight loss is the most direct indicator of reduced fluid volume due to diuresis.
A nurse is teaching a client about the use of an incentive spirometer. Which of the following instructions should the nurse include in the teaching?
- A. Hold breaths about 3 to 5 seconds before exhaling.'
- B. Exhale slowly through pursed lips.'
- C. Position the mouthpiece 2.5 cm (1 in) from the mouth.'
- D. Place hands on the upper abdomen during inhalation.'
Correct Answer: A
Rationale: Correct Answer: A. Hold breaths about 3 to 5 seconds before exhaling.
Rationale: Holding the breath for a few seconds after inhaling with an incentive spirometer helps to fully expand the lungs and improve lung function. This technique prevents air from escaping too quickly and allows for optimal oxygen absorption. It also encourages deep breathing, which is essential for clearing the airways and improving overall lung capacity.
Summary of other choices:
B: Exhaling slowly through pursed lips is a technique used in pursed lip breathing, not with an incentive spirometer.
C: The position of the mouthpiece is important for comfort but not directly related to using the incentive spirometer.
D: Placing hands on the upper abdomen during inhalation is not a recommended technique for using an incentive spirometer.
A nurse is analyzing the ABG results of a client who is in respiratory acidosis. Which of the following mechanisms should the nurse identify as responsible for this acid-base imbalance?
- A. Retention of carbon dioxide
- B. Loss of bicarbonate
- C. Excessive vomiting
- D. Hyperventilation
Correct Answer: A
Rationale: The correct answer is A: Retention of carbon dioxide. In respiratory acidosis, there is an excess of carbon dioxide (CO2) in the blood, leading to a decrease in pH. This imbalance occurs when the lungs are unable to eliminate enough CO2 through respiration, causing it to accumulate in the bloodstream. This excess CO2 combines with water in the blood to form carbonic acid, leading to acidosis. Choices B, C, and D are incorrect as they do not directly relate to the accumulation of CO2 in respiratory acidosis. Loss of bicarbonate (B) would lead to metabolic acidosis, excessive vomiting (C) would cause metabolic alkalosis, and hyperventilation (D) would actually help in decreasing CO2 levels, which is not the case in respiratory acidosis.