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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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An adult is receiving Gantrisin 1 g PO qid for a urinary tract infection. Which statement that she makes indicates a need for more teaching?
- A. If I get a rash, I will apply calamine lotion.
- B. I will take my pills with a full glass of water.
- C. I will take all the pills even if I feel better.
- D. I will stay out of the sun while I am taking the pills.
Correct Answer: A
Rationale: A rash may indicate an adverse reaction to Gantrisin, requiring physician consultation, not self-treatment with calamine lotion.
A client newly diagnosed with Type I Diabetes Mellitus asks the purpose of the test measuring glycosylated hemoglobin. The nurse should explain that the purpose of this test is to determine:
- A. The presence of anemia often associated with Diabetes
- B. The oxygen carrying capacity of the client's red cells
- C. The average blood glucose for the past 2-3 months
- D. The client's risk for cardiac complications
Correct Answer: C
Rationale: The average blood glucose for the past 2-3 months. By testing the portion of the hemoglobin that absorbs glucose, it is possible to determine the average blood glucose over the life span of the red cell, 120 days.
An adult is hospitalized for an acute attack of gout. Which medication should the nurse expect to administer?
- A. Morphine
- B. Colchicine
- C. Allopurinol
- D. Acetaminophen
Correct Answer: B
Rationale: Colchicine is used to treat acute gout attacks by reducing inflammation, unlike allopurinol, which prevents attacks.
An adult received regular insulin at 7:00 A.M. At 10:00 A.M., she is irritable and sweaty, but her skin is cool. What is the most appropriate action for the nurse to take?
- A. Have her lie down for a rest
- B. Give her a cola drink
- C. Give ordered insulin
- D. Encourage exercise
Correct Answer: B
Rationale: Irritability, sweating, and cool skin suggest hypoglycemia. A cola drink provides quick-acting carbohydrates to raise blood sugar.
The client in the intensive care department is receiving 2 mcg/kg/min of dopamine, an inotropic vasopressor. Which intervention should the nurse include in the plan of care?
- A. Monitor the client's blood pressure every two (2) hours.
- B. Assess the client's peripheral pulses every shift.
- C. Use a urometer to assess hourly output.
- D. Ensure the IV tubing is not exposed to the light.
Correct Answer: C
Rationale: Dopamine affects renal perfusion; hourly urine output via urometer monitors efficacy and prevents toxicity. BP, pulses, or light exposure are less critical.