Nokea
The home health nurse is discussing the administration of insulin glargine with a client. It would require follow-up if the client states that insulin glargine must be administered
- A. only in the abdomen.
- B. using a 6 mm and 31-gauge insulin syringe.
- C. only with a meal.
- D. after rolling the vial of insulin.
- E. within 28 days of opening the vial.
Correct Answer: A,C,D
Rationale: Insulin glargine can be administered in multiple sites, not only the abdomen; it is given regardless of meals; and it should not be rolled, as it is a clear solution.
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When assessing the client with Hodgkin's disease, the nurse should observe the client for which of the following?
- A. Herpes zoster infections.
- B. Discolored teeth.
- C. Hemorrhage.
- D. Hypercellular immunity.
Correct Answer: A
Rationale: Hodgkin's disease impairs immune function, increasing the risk of infections like herpes zoster (shingles). Discolored teeth, hemorrhage, and hypercellular immunity are not typical findings.
A client has been diagnosed with vasospastic disorder (Raynaud's phenomenon) on the tip of the nose and fingertips. The physician has prescribed reserpine (Serpasil) to determine if the client will obtain relief. The client's history reveals that he lives in Vermont and works outside in the logging industry. He smokes two packs of cigarettes a day. Which of the following components are an important part of the discharge plan for this client? Select all that apply.
- A. Stopping smoking
- B. Wearing a face covering and gloves in the winter
- C. Placing fingertips in cool water to rewarm them
- D. Finding employment that can be done in a warm environment
- E. Reporting signs of orthostatic hypotension
Correct Answer: A,B,D,E
Rationale: Rationales: A) Stopping smoking reduces vasoconstriction triggered by nicotine, critical in Raynaud's. B) Face covering and gloves protect against cold, a trigger for vasospasm. D) Working in a warm environment minimizes cold exposure. E) Reserpine may cause orthostatic hypotension, requiring monitoring. C) Cool water worsens vasospasm; warm water is recommended.
The nurse instructs the unlicensed nursing personnel (UAP) on how to provide oral hygiene for a client who cannot perform this task for himself. Which of the following techniques should the nurse tell the UAP to incorporate into the client's daily care?
- A. Assess the oral cavity each time mouth care is given and record observations.
- B. Use a soft toothbrush to brush the client's teeth after each meal.
- C. Swab the client's tongue, gums, and lips with a soft foam applicator every 2 hours.
- D. Rinse the client's mouth with mouthwash several times a day.
Correct Answer: B
Rationale: Using a soft toothbrush after meals is an effective and safe method for providing oral hygiene, promoting cleanliness without causing trauma.
A male client who has been taking warfarin (Coumadin) has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL; and hematocrit, 33%. Which of the following physician orders should the nurse expect to implement initially? Select all that apply.
- A. Administer I.V. dextrose 5% in 0.45% normal saline solution.
- B. Schedule client for a sigmoidoscopy in the morning.
- C. Give 1 unit fresh frozen plasma (FFP).
- D. Administer vitamin K (AquaMEPHYTON) 2.5 mg.
- E. Begin giving polyethylene glycol-electrolyte solution (GoLYTELY) in preparation for sigmoidoscopy.
- F. Administer Fleet enema.
Correct Answer: C,D
Rationale: An INR of 8 indicates excessive anticoagulation from warfarin, causing severe bleeding. Initial management includes administering fresh frozen plasma (FFP) to replace clotting factors and vitamin K to reverse warfarin's effects. Dextrose/saline, sigmoidoscopy preparation, and enemas are not immediate priorities.
The nurse is assessing a client who has had a myocardial infarction. The nurse notes the cardiac rhythm shown on the electrocardiogram strip below. The nurse identifies this rhythm as which of the following?
- A. Atrial fibrillation.
- B. Ventricular tachycardia.
- C. Premature ventricular contractions.
- D. Sinus tachycardia.
Correct Answer: D
Rationale: Sinus tachycardia is a fast but regular rhythm originating from the sinoatrial node, typically occurring in response to factors like pain, fever, anxiety, or myocardial infarction.