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The nurse administered neutral protamine Hagedorn (NPH) insulin to a diabetic client at 7am. At what time would the nurse expect the client to be at most risk for a hypoglycemic reaction?
- A. 10:00 AM
- B. 4:00 PM
- C. Noon
- D. 10:00 PM
Correct Answer: D
Rationale: NPH insulin typically peaks in its action around 6-10 hours after administration. Therefore, after administering NPH insulin at 7am, the client would be at most risk for a hypoglycemic reaction around 10pm. This is when the insulin is exerting its strongest effect, potentially leading to lower blood sugar levels. Monitoring for hypoglycemia during this time frame is crucial to ensure prompt intervention if needed.
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A nurse is assigned to four children of different ages. In which age group should the nurse understand that body integrity is a concern? TestBankWorld.org
- A. Toddler
- B. Preschooler
- C. School-age child
- D. Adolescent
Correct Answer: D
Rationale: Body integrity becomes a concern in adolescence, which is the period of development marked by rapid physical changes and self-awareness. Adolescents may experience body image issues, peer pressure, and the desire to conform to societal standards, which can lead to behaviors that compromise their body integrity, such as risky behaviors, eating disorders, self-harm, or seeking cosmetic procedures. By understanding the concerns surrounding body integrity in adolescents, the nurse can provide appropriate support, education, and guidance to promote healthy body image and self-esteem.
The nurse is preparing an adolescent for discharge after a cardiac catheterization. Which statement by the adolescent would indicate a need for further teaching?
- A. "I should avoid tub baths but may shower."
- B. "I have to stay on strict bed rest for 3 days."
- C. "I should remove the pressure dressing the day after the procedure."
- D. "I may attend school but should avoid exercise for several days."
Correct Answer: B
Rationale: The statement "I have to stay on strict bed rest for 3 days" would indicate a need for further teaching. After a cardiac catheterization, strict bed rest is usually not required for an extended period of time. The patient is typically advised to limit physical activities for a certain period but can engage in light activities as tolerated. Prolonged bed rest can increase the risk of complications such as blood clots and muscle weakness. It would be important to clarify this misconception and provide accurate information regarding post-procedure care.
What instruction should the nurse give to then patient taking propan0lol (Inderal) for hypertension?
- A. Have potassium level checked
- B. Do not stop medication abruptly
- C. Report any changes in appetite
- D. Resume usual daily activities
Correct Answer: B
Rationale: The nurse should instruct the patient taking propranolol (Inderal) for hypertension to not stop the medication abruptly. Suddenly stopping propranolol can lead to rebound hypertension and potentially dangerous side effects. It is important for the patient to gradually taper off the medication under the guidance of a healthcare provider to avoid complications. Therefore, advising the patient not to stop the medication abruptly is a crucial instruction to ensure their safety and well-being.
Which of the following is the most common symptoms of pericarditis?
- A. Dyspnea c.Chest pain
- B. Intermittent claudication
- C. Calf pain
Correct Answer: A
Rationale: The most common symptom of pericarditis is chest pain. This chest pain is typically sharp and stabbing, and it may worsen when taking deep breaths or lying down. It can also be relieved by sitting up or leaning forward. Other symptoms of pericarditis may include dyspnea (shortness of breath), but chest pain is the hallmark symptom that differentiates pericarditis from other conditions. Intermittent claudication and calf pain are not typically associated with pericarditis.
To whom is RhIG (RhoGAM) administered to prevent Rh isoimmunization?
- A. Rh-negative women who deliver an Rh-positive newborn
- B. Rh-positive women who deliver an Rh-negative newborn
- C. Rh-negative newborns whose mothers are Rh positive
- D. Rh-positive fathers before conception of second newborn when first newborn was Rh positive
Correct Answer: A
Rationale: RhIG (RhoGAM) is administered to Rh-negative women who deliver an Rh-positive newborn to prevent Rh isoimmunization. Rh isoimmunization can occur when an Rh-negative mother is exposed to Rh-positive fetal blood during childbirth, leading to the production of antibodies against Rh antigen. RhIG works by binding to and destroying any fetal Rh-positive red blood cells that have entered the mother's circulation, preventing her immune system from mounting an immune response and producing antibodies. This helps to protect subsequent pregnancies from complications related to Rh isoimmunization. Therefore, RhIG administration is crucial in preventing sensitization and ensuring the health of future pregnancies in Rh-negative women who deliver an Rh-positive newborn.