Nokea
An adult received regular insulin at 7:00 A.M. At 10:00 A.M., she is irritable and sweaty, but her skin is cool. What is the most appropriate action for the nurse to take?
- A. Have her lie down for a rest
- B. Give her a cola drink
- C. Give ordered insulin
- D. Encourage exercise
Correct Answer: B
Rationale: Irritability, sweating, and cool skin suggest hypoglycemia. A cola drink provides quick-acting carbohydrates to raise blood sugar.
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An adult client has been diagnosed as having rheumatoid arthritis and is started on piroxicam (Feldene) 20 mg daily. Two days later, the client calls the nurse and says that her joints still hurt. What is the best response for the nurse to make?
- A. It may take up to two weeks before results are seen with Feldene.
- B. Take aspirin with the Feldene. It has an additive effect.
- C. Come in to see the physician. You should have pain relief by now.
- D. You may need more medication. Take one additional pill each day.
Correct Answer: A
Rationale: Piroxicam, an NSAID, may take up to two weeks for full anti-inflammatory effects.
An adult is hospitalized for an acute attack of gout. Which medication should the nurse expect to administer?
- A. Morphine
- B. Colchicine
- C. Allopurinol
- D. Acetaminophen
Correct Answer: B
Rationale: Colchicine is used to treat acute gout attacks by reducing inflammation, unlike allopurinol, which prevents attacks.
A client newly diagnosed with Type I Diabetes Mellitus asks the purpose of the test measuring glycosylated hemoglobin. The nurse should explain that the purpose of this test is to determine:
- A. The presence of anemia often associated with Diabetes
- B. The oxygen carrying capacity of the client's red cells
- C. The average blood glucose for the past 2-3 months
- D. The client's risk for cardiac complications
Correct Answer: C
Rationale: The average blood glucose for the past 2-3 months. By testing the portion of the hemoglobin that absorbs glucose, it is possible to determine the average blood glucose over the life span of the red cell, 120 days.
The client is diagnosed with essential hypertension and is receiving a calcium channel blocker. Which assessment data would warrant the nurse holding the client's medication?
- A. The client's oral temperature is 102°F.
- B. The client complains of a dry, nonproductive cough.
- C. The client's blood pressure reading is 106/76.
- D. The client complains of being dizzy when getting out of bed.
Correct Answer: D
Rationale: Dizziness on standing suggests orthostatic hypotension, a calcium channel blocker side effect, warranting holding the dose to prevent falls. Fever, cough, or BP are less critical.
The client on bedrest is receiving enoxaparin (Lovenox), a low molecular weight heparin. Which anatomical site is recommended for administering this medication?
- A. The abdominal wall one (1) inch away from the umbilicus.
- B. The vastus lateralis with a 23-gauge needle.
- C. In the deltoid area subcutaneously.
- D. In the anterolateral abdomen.
Correct Answer: D
Rationale: Enoxaparin is injected subcutaneously in the anterolateral abdomen for optimal absorption and minimal bruising, per manufacturer guidelines.