Nokea
Glulisine (Apidra) insulin is ordered to be administered to a client before each meal. To assist the day-shift nurse who is receiving the report, the night-shift nurse gives the morning dose of glulisine. When the day-shift nurse goes to the room of the client who requires glulisine, the nurse finds that the client is not in the room. The client's roommate tells the nurse that the client 'went for a test.' What should the nurse do next?
- A. Bring a small glass of juice, and locate the client.
- B. Call the client's physician.
- C. Check the computerized care plan to determine the test.
- D. Send the nurse's assistant to the X-ray department to bring the client back to his room.
Correct Answer: A
Rationale: Glulisine is rapid-acting insulin, and the client must eat within 15 minutes to prevent hypoglycemia. The nurse should locate the client and provide juice to counteract potential hypoglycemia.
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Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus. Select all that apply.
- A. A major risk factor for complications is obesity and central abdominal obesity.
- B. Supplemental insulin is mandatory for controlling the disease.
- C. Exercise increases insulin resistance.
- D. The primary nutritional source requiring monitoring in the diet is carbohydrates.
- E. Annual eye and foot examinations are recommended by the American Diabetes Association (ADA).
Correct Answer: A,D,E
Rationale: Obesity, especially central, is a major risk factor for complications. Carbohydrates require monitoring to manage blood glucose. Annual eye and foot exams are recommended. Insulin is not mandatory for type 2 diabetes, and exercise decreases insulin resistance.
A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for the client?
- A. Avoid activities that elicit the Valsalva maneuver.
- B. Take aspirin to control nasal discomfort.
- C. Avoid brushing the teeth until the nasal packing is removed.
- D. Apply heat to the nasal area to control swelling.
Correct Answer: A
Rationale: Avoiding the Valsalva maneuver (e.g., straining) prevents increased pressure that could dislodge packing or cause bleeding. Aspirin increases bleeding risk. Tooth brushing is safe with care. Heat may increase swelling; cold is preferred.
The nurse finds it difficult to relieve a client's pain satisfactorily. Which of the following measures should the nurse take next when continuing efforts to promote comfort?
- A. Improve the nurse-client relationship.
- B. Enlist the help of the client's family.
- C. Allow the client additional time to work through his or her own responses to pain.
- D. Arrange to have the client share a room with a client who has little pain.
Correct Answer: A
Rationale: Improving the nurse-client relationship fosters trust, enhancing pain management through better communication and tailored interventions. Family help, time, or room sharing are less direct solutions.
The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this to monitor for signs of which of the following?
- A. External hemorrhage.
- B. Decreasing level of consciousness.
- C. Laryngeal nerve damage.
- D. Upper airway obstruction.
Correct Answer: C
Rationale: Asking the client to speak monitors for laryngeal nerve damage, which can cause vocal cord paralysis and hoarseness, a potential complication of thyroidectomy.
The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:
- A. Turning every 2 hours
- B. Passive and active range-of-motion exercises
- C. Use of thromboembolic disease support (TED) hose
- D. Maintaining the client in the supine position
Correct Answer: D
Rationale: Maintaining the client in the supine position is not recommended, as it promotes stasis and pressure ulcers. Turning every 2 hours, range-of-motion exercises, and TED hose prevent complications like thrombophlebitis and skin breakdown during bed rest.