Nokea
Mr. Gary is a 67 year old client who is experiencing chronic pain. Which of the following is the best way to assess his pain?
- A. Observe his behavior
- B. Ask him to describe his pain
- C. Perform physical assessment
- D. Use a standardized pain scale
Correct Answer: D
Rationale: For Mr. Gary's chronic pain at 67, a standardized pain scale (D) best assesses intensity, per pain management standards (e.g., numeric scale). Observation (A) misses subjectivity, description (B) lacks precision, physical assessment (C) is secondary. Scales quantify chronic pain reliably, especially in older adults, making D the optimal choice.
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The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)?
- A. Stridor
- B. Lung congestion
- C. Occasional pink-tinged sputum
- D. Respiratory rate of 26 breaths per minute
Correct Answer: A
Rationale: Post-extubation after radical neck dissection, stridor (A) indicates airway obstruction (e.g., edema, laryngospasm), requiring immediate RN reporting. Lung congestion (B) or pink sputum (C) suggest fluid but are less urgent. A rate of 26 (D) is elevated but not critical alone. A is correct. Rationale: Stridor signals potential airway compromise, a life-threatening emergency post-neck surgery due to swelling or structural changes, necessitating rapid intervention like reintubation or steroids, per post-operative care standards, unlike less acute findings.
Which of the following statement is NOT true about standards of care?
- A. Guide nursing practice
- B. Based on evidence
- C. Vary by nurse
- D. Ensure quality
Correct Answer: C
Rationale: Standards guide practice (A), are evidence-based (B), ensure quality (D) 'vary by nurse' (C) isn't true, uniform, per regulation. C's variation contradicts consistency for Mr. Gary's care, making it untrue.
A healthcare professional is supervising a newly licensed colleague who is preparing to administer an intramuscular injection. Which of the following actions by the newly licensed colleague requires intervention?
- A. Selecting a 25-gauge needle
- B. Administering the injection at a 45° angle
- C. Using the ventrogluteal site for the injection
- D. Aspirating for blood return before injecting the medication
Correct Answer: B
Rationale: The correct answer is B. Administering an intramuscular injection at a 90° angle is essential for proper medication delivery into the muscle tissue. Injecting at a 45° angle is incorrect for intramuscular injections and is typically used for subcutaneous injections where the needle is inserted into the fatty tissue layer beneath the skin. Choice A is correct as selecting a 25-gauge needle is appropriate for an intramuscular injection. Choice C is also correct as the ventrogluteal site is a suitable site for intramuscular injections. Choice D is correct as aspirating for blood return is a necessary step to ensure the needle is not in a blood vessel before injecting the medication.
A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
- B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
- C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
- D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.
Correct Answer: A
Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.
The nurse is preparing to administer regular insulin to a client with type 1 diabetes. Before administering the insulin, the nurse should:
- A. Rotate the vial between her hands
- B. Warm the insulin to body temperature
- C. Shake the vial vigorously
- D. Draw up the insulin with an 18-gauge needle
Correct Answer: A
Rationale: Rotating the vial between hands mixes regular insulin gently, ensuring even suspension without denaturing it warming, shaking, or large needles risk potency loss or tissue damage. Nurses use this technique, confirming clarity, for safe, effective glycemic control in type 1 diabetes.