Nokea
The client has an order for sliding scale insulin at 1900 hours and Lantus (glargine) insulin at the same hour. The nurse should:
- A. Administer the two medications together.
- B. Administer the two medications in two injections.
- C. Draw up the Lantus insulin and then the regular insulin and administer them together.
- D. Contact the doctor because these medications should not be given to the same client.
Correct Answer: B
Rationale: Lantus (glargine) is a long-acting insulin and should not be mixed with short-acting sliding scale insulin (e.g. regular insulin) due to differing pharmacokinetics. Administering them in separate injections ensures proper action profiles.
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A client on a mechanical ventilator begins to fight the ventilator. Which medication will be ordered for the client?
- A. Sublimaze (fentanyl)
- B. Pavulon (pancuronium bromide)
- C. Versed (midazolam)
- D. Atarax (hydroxyzine)
Correct Answer: B
Rationale: Pancuronium bromide, a neuromuscular blocker, paralyzes muscles to prevent fighting the ventilator, ensuring effective ventilation. Sedatives like midazolam or fentanyl are secondary.
A client is having a vertical partial laryngectomy, and the nurse is planning his postoperative care. A priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy would be:
- A. Airway obstruction
- B. Communication impairment
- C. Pain management
- D. Infection risk
Correct Answer: C
Rationale: Pain management is a priority postoperative nursing diagnosis for a client having a vertical partial laryngectomy due to the surgical incision and tissue trauma, which can cause significant discomfort. Effective pain control is essential to promote recovery and patient comfort.
A male client was diagnosed 6 months ago with amyotrophic lateral sclerosis (ALS). The progression of the disease has been aggressive. He is unable to maintain his personal hygiene without assistance. Ambulation is most difficult, requiring him to use a wheelchair and rely on assistance for mobility. He recently has become severely dysphasic. Nursing interventions for dysphasia would be aimed toward prevention of:
- A. Loss of ability to speak and communicate effectively
- B. Aspiration and weight loss
- C. Secondary infection resulting from poor oral hygiene
- D. Drooling
Correct Answer: B
Rationale: Loss of ability to speak is not dysphasia. Although the client may have difficulty communicating, alternative measures can be developed to enhance communication. This goal, while important, is of a lesser priority. Dysphasia is difficulty swallowing, which could result in aspiration of food and inability to eat, causing weight loss. A secondary infection could result from poor oral hygiene, which could enhance the client's inability to eat, but this goal is of a lesser priority. Drooling normally occurs in clients with amyotrophic lateral sclerosis and may require suctioning. Drooling, while aggravating for the client, does not pose an immediate danger.
The nurse is caring for a client with a diagnosis of postpartum endometritis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for cesarean delivery
- D. Administer tocolytics
Correct Answer: A
Rationale: Postpartumndometritis require es antibiotics to treat the uterine infection. Fetal heart tones are irrelevant postpartum cesarean delivery is not indicated and tocolytics are for preterm labor.
Which set of vital signs would best indicate to the nurse that a client has an increase in intracranial pressure?
- A. BP 180/70, pulse 50, respirations 16, temperature 101°F
- B. BP 100/70, pulse 64, respirations 20, temperature 98.6°F
- C. BP 96/70, pulse 132, respirations 20, temperature 98.6°F
- D. BP 130/80, pulse 50, respirations 18, temperature 99.6°F
Correct Answer: A
Rationale: Increased ICP is indicated by Cushing’s triad: hypertension (BP 180/70), bradycardia (pulse 50), and irregular respirations. Option A best matches this, with fever as a possible secondary sign. Options B, C, and D lack this combination.