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A nurse is providing teaching to a client who has diabetes mellitus and a new prescription for insulin glargine. Which of the following instructions should the nurse include?
- A. You should inject this medication once a day, at the same time each day.
- B. You should expect your blood glucose level to increase immediately after administration.
- C. You should rotate injection sites between your abdomen and thigh.
- D. You should inject this medication with your meals.
Correct Answer: A
Rationale: The correct instruction that the nurse should include is to inject insulin glargine once a day, at the same time each day. Insulin glargine is a long-acting insulin that provides a consistent level of insulin over 24 hours, helping to maintain stable blood glucose levels. Option B is incorrect because insulin glargine does not cause an immediate increase in blood glucose levels. Option C is important for preventing lipodystrophy but is not specific to insulin glargine administration. Option D is incorrect because insulin glargine is typically administered at the same time each day, regardless of meals.
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A client receiving warfarin is being taught by a nurse. Which of the following client statements indicates an understanding of the teaching?
- A. I will avoid eating leafy green vegetables while taking this medication.
- B. I will need to have my INR checked regularly while taking this medication.
- C. I will take this medication at the same time each day.
- D. I will avoid taking aspirin while taking this medication.
Correct Answer: D
Rationale: The correct answer is D because clients taking warfarin should avoid aspirin to reduce the risk of bleeding, as both medications can thin the blood. Choice A is incorrect because it is essential to eat a consistent amount of leafy green vegetables to maintain a steady intake of Vitamin K, which can impact warfarin's effectiveness. Choice B is incorrect although important because INR checks are necessary but do not specifically show an understanding of the teaching. Choice C is incorrect because while taking warfarin at the same time each day is beneficial for consistency, it does not directly address the interaction with aspirin.
A charge nurse is teaching a group of nurses about delegation. Which task should the nurse delegate to assistive personnel (AP)?
- A. Teaching a new mother how to breastfeed.
- B. Assisting a client with ambulation post-surgery.
- C. Helping with medication administration.
- D. Delegating IV medication administration.
Correct Answer: B
Rationale: The correct answer is B. Assisting a client with ambulation post-surgery is a task that can be appropriately delegated to assistive personnel (AP) as it falls within their scope of duties. Teaching a new mother how to breastfeed and helping with medication administration involve assessments and critical thinking that are typically within the scope of licensed nursing staff, not AP. Delegating IV medication administration involves a higher level of skill and knowledge that should be performed by licensed nursing staff.
A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client?
- A. Personal blogs about managing the adverse effects of diabetes medications.
- B. Food label recommendations from the Institute of Medicine.
- C. Diabetes medication information from the Physicians' Desk Reference.
- D. Food exchange lists for meal planning from the American Diabetes Association.
Correct Answer: D
Rationale: The correct answer is D. Food exchange lists from the American Diabetes Association are valuable resources for individuals with diabetes as they provide specific guidance on meal planning and portion control, which are crucial for managing blood sugar levels. Choice A is incorrect because personal blogs may not always provide accurate or evidence-based information. Choice B is incorrect as food label recommendations, while important, may not offer the structured guidance needed for meal planning in diabetes. Choice C is also incorrect as medication information is different from dietary guidance needed for diabetes management.
A nurse is providing teaching to a client who is receiving radiation therapy for cancer of the larynx. Which of the following instructions should the nurse include?
- A. Apply heat to the neck to relieve pain.
- B. Use a soft-bristle toothbrush to prevent gum irritation.
- C. Rinse your mouth with an alcohol-free mouthwash twice daily.
- D. Wear loose-fitting clothing to protect your skin.
Correct Answer: B
Rationale: The correct answer is to use a soft-bristle toothbrush to prevent gum irritation in clients undergoing radiation therapy for laryngeal cancer. Radiation therapy can cause oral mucositis and increase the risk of gum irritation, so using a soft-bristle toothbrush is recommended to minimize trauma to the gums and oral mucosa. Applying heat to the neck is contraindicated as it can exacerbate tissue damage caused by radiation. Rinsing the mouth with an alcohol-free mouthwash is preferred over an alcohol-based one to prevent drying and irritation of the oral mucosa. Wearing loose-fitting clothing is advised to prevent friction and irritation on the skin, rather than tight-fitting clothing that may cause pressure ulcers or skin breakdown.
A nurse is preparing to administer a dose of digoxin to a client who has heart failure. Which of the following actions should the nurse take prior to administering the medication?
- A. Monitor the client's respiratory rate.
- B. Assess the client's apical pulse.
- C. Review the client's potassium level.
- D. Monitor the client's fluid intake.
Correct Answer: B
Rationale: The correct action the nurse should take prior to administering digoxin is to assess the client's apical pulse. Digoxin is known to affect the heart rate, potentially causing bradycardia. Monitoring the client's respiratory rate (Choice A) is not directly related to administering digoxin. Reviewing the client's potassium level (Choice C) is important but not a direct prerequisite for administering digoxin. Monitoring the client's fluid intake (Choice D) is also important but not a specific action to take just before administering digoxin.