Nokea
Based on knowledge of cultural diversity, the nurse knows that obtaining a CBC will be most distressing for the client who is:
- A. Asian
- B. African-American
- C. Latino
- D. Native American
Correct Answer: D
Rationale: Some Native American cultures believe blood removal weakens the body or spirit, making a CBC distressing. Other groups typically do not have this belief.
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The spouse of a client calls the nurse at the clinic and reports that the client is not feeling well and is concerned that something is seriously wrong. How should the nurse respond initially?
- A. Ask the spouse to further describe the client's symptoms
- B. Indicate that privacy rules prevent discussion of concerns with the spouse
- C. Offer a same-day appointment to the client
- D. Tell the spouse to have the client call the nurse
Correct Answer: A
Rationale: Asking for symptom details helps assess urgency without violating privacy, as the spouse initiated contact. Privacy rules don't preclude initial fact-gathering, but direct client contact or an appointment may follow based on severity.
The nurse in a residence facility for older adults is planning for the year. During which month should the influenza vaccine be offered to the residents?
- A. May
- B. July
- C. September
- D. November
Correct Answer: C
Rationale: September allows influenza vaccination before the flu season peaks, ensuring immunity. Later or earlier months are less optimal.
A 6-month-old infant is being seen in the doctor's office. Which observation by the nurse should be brought to the physician's attention?
- A. The baby sits up but needs slight support.
- B. The baby was 7 lb at birth and now weighs 10 lb.
- C. The baby frequently drops objects and looks for them.
- D. The baby smacks her lips and drools.
Correct Answer: B
Rationale: A 6-month-old should double birth weight (14 lb expected for 7 lb); 10 lb suggests poor growth, requiring evaluation. Other findings are developmentally normal.
Medication administration record
Allergies: No Known Allergies
Sliding scale blood glucose levels, regular insulin dose
<150 mg/dL (<8.3 mmol/L), O units
150-199 mg/dL (8.3-11.0 mmol/L), 2 units
200-249 mg/dL (11.1-13.8 mmoV/L), 4 units
250-299 mg/dL (13.9-16.6 mmol/L), 6 units
≥300 mg/dL (≥16.7 mmol/L), 8 units and notify health care provider
A client with type 1 diabetes has a prescription for 30 units of insulin glargine at bedtime. Fingerstick blood glucose measurements are prescribed before meals and at bedtime with regular insulin based on a sliding scale. At 9 PM, the client's blood glucose measurement is 180 mg/dL (10.0 mmol/L). What action should the nurse take?
- A. Administer 30 units of glargine; give the client a snack, then administer 2 units of regular insulin
- B. Administer 30 units of glargine and 2 units of regular insulin in 2 different injections
- C. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the glargine first
- D. Mix 30 units of glargine with 2 units of regular insulin in the same syringe, drawing up the regular insulin first
Correct Answer: B
Rationale: The sliding scale indicates 2 units of regular insulin for a glucose of 180 mg/dL. Glargine, a long-acting insulin, should be given as prescribed (30 units). Glargine cannot be mixed with regular insulin in the same syringe due to differing pH levels, so separate injections are required.
The nurse is observing a nursing assistant transfer a client from bed to chair. Which observation needs correction? Select all that apply.
- A. The nursing assistant lowers the bed before starting the procedure.
- B. The nursing assistant sits the client on the side of the bed before assisting the client to move.
- C. The nursing assistant stands with feet close together and knees and back straight when helping the client to move.
- D. The nursing assistant asks the client to grab the arm of the nursing assistant during the transfer.
- E. The nursing assistant lifts the client up by tugging on the client's arms.
- F. The nursing assistant assists the client to stand and pivot to get into the chair.
Correct Answer: C,D,E
Rationale: The nursing assistant should stand with feet apart and knees bent to prevent injury, not grab the client's arm, and avoid tugging on the client's arms. Lowering the bed, sitting the client up, and assisting to pivot are correct.