Nokea
A patient with type I diabetes mellitus (IDDM) asks the nurse why the doctor ordered human insulin instead of beef or pork insulin. Which of the following responses by the nurse is BEST?
- A. Human insulin is less likely to cause you to have a localized allergic reaction to the injection.'
- B. Human insulin will cause you to experience fewer problems with hypoglycemia or hyperglycemia.'
- C. Human insulin prevents the development of long-term damage to the eyes and kidneys.'
- D. Human insulin does not cause the formation of antibodies because the protein structure is identical to your own.'
Correct Answer: D
Rationale: protein molecules are identical with human insulin
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Which one of the following rights is included in the Patient's Bill of Rights?
- A. The right to expect reasonable continuity of care
- B. The right to complete privacy
- C. The right to confidentiality
- D. The right to advanced directives concerning treatment
Correct Answer: C
Rationale: The Patient's Bill of Rights includes the right to confidentiality. Continuity, privacy, and advance directives are important but not explicitly listed as primary rights.
Prior to suctioning a tracheotomy, the nurse should:
- A. Suction the oropharynx.
- B. Administer oxygen.
- C. Change the inner cannula.
- D. Raise the head of the bed.
Correct Answer: B
Rationale: Administering oxygen pre-suctioning prevents hypoxia, as suctioning can reduce oxygen levels. Oropharyngeal suctioning, cannula changes, or bed elevation are not primary pre-suction steps.
After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room.
- A. Which assessment finding three hours after admission should be reported to the physician for a five-year-old with a closed head injury?
- B. The client has slight edema of the eyelids.
- C. There is clear fluid draining from the client’s right ear.
- D. There is some bleeding from the child’s lacerations.
- E. The client withdraws in response to painful stimuli.
Correct Answer: B
Rationale: Clear fluid draining from the ear suggests cerebrospinal fluid (CSF) leakage due to a meningeal rupture, a serious complication that risks meningitis and requires immediate reporting. Eyelid edema, minor bleeding, and withdrawal to pain are less urgent or expected findings.
The nurse is caring for a client with a history of hemophilia.
- A. Which intervention is most important for a client with hemophilia experiencing joint pain?
- B. Administer factor replacement therapy.
- C. Apply warm compresses to the joint.
- D. Encourage active range-of-motion exercises.
- E. Administer oral analgesics.
Correct Answer: A
Rationale: Factor replacement therapy stops bleeding in hemophilia, relieving joint pain from hemarthrosis. Cold compresses are used, exercise worsens bleeding, and analgesics are supportive.
A client with tuberculosis is started on Rifampin. Which one of the following statements by the nurse would be appropriate to include in teaching? 'You may notice:
- A. an orange-red color to your urine.'
- B. your appetite may increase for the first week.'
- C. it is common to experience occasional sleep disturbances.'
- D. if you take the medication with food, you may have nausea.'
Correct Answer: A
Rationale: Discoloration of the urine and other body fluids may occur. It is a harmless response to the drug, but the patient needs to be aware it may happen.