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The nurse administers 18 units of Humulin N, an intermediate-acting insulin, at 1630. Which priority intervention should the nurse implement?
- A. Monitor the client's hemoglobin A1c.
- B. Make sure the client eats the evening meal.
- C. Check the a.c. blood glucometer reading.
- D. Ensure the client eats a snack.
Correct Answer: B
Rationale: Humulin N peaks in 4–12 hours; evening meal prevents hypoglycemia during peak action. A1c, a.c. checks, or snacks are less immediate.
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The client diagnosed with migraine headaches is prescribed propranolol (Inderal), a beta blocker, for prophylaxis. Which information should the nurse teach the client?
- A. Instruct to take the medication at the first sign of headache.
- B. Teach the client to take his or her radial pulse for one (1) minute.
- C. Explain this drug may make the client thirsty and have a dry mouth.
- D. Discuss the need to increase artificial light in the home.
Correct Answer: B
Rationale: Propranolol can cause bradycardia; teaching pulse monitoring ensures safety. It’s prophylactic, not acute, and dry mouth or lighting are unrelated.
The client with coronary artery disease is prescribed one (1) baby aspirin a day. Which instructions should the nurse provide the client concerning this medication?
- A. Take the medication on an empty stomach.
- B. Do not take Tylenol while taking this drug.
- C. If experiencing joint pain, notify the HCP.
- D. Notify the HCP if stools become dark and tarry.
Correct Answer: D
Rationale: Dark, tarry stools suggest GI bleeding, a serious aspirin side effect, requiring HCP notification. Empty stomach, Tylenol, or joint pain are less critical.
The client's vital signs are T 99.2°F, AP 59, R 20, and BP 108/72. Which medication would the nurse question administering?
- A. Theo-Dur, a bronchodilator.
- B. Inderal, a beta blocker.
- C. Ampicillin, an antibiotic.
- D. Cardizem, a calcium channel blocker.
Correct Answer: B
Rationale: Inderal (propranolol) slows HR; an apical pulse of 59 warrants holding it, per guidelines, to avoid bradycardia. Other meds are unaffected by HR.
Which observation, if reported by a client, is most suggestive of an adverse reaction to gentamicin?
- A. A WBC of 8000
- B. Ringing in the ears
- C. Itching
- D. Nasal stuffiness
Correct Answer: B
Rationale: Gentamicin is ototoxic. Ringing in the ears suggests possible damage to the eighth cranial nerve, the auditory nerve. A WBC of 8000 is normal.
A 6-year-old child is seen in the emergency room after stepping on a rusty nail. He has received no immunizations. What should the nurse expect to give him immediately to prevent a tetanus infection?
- A. Tetanus toxoid
- B. DTaP
- C. Immune serum globulin
- D. Penicillin
Correct Answer: C
Rationale: Immune serum globulin provides immediate passive immunity against tetanus in an unimmunized child.