Nokea
The nurse administers 6 units of Humalog (lispro) insulin sub-q to a client at 8:30 a.m. The nurse knows to reassess the client and check for a possible hypoglycemic reaction at
- A. 8:45 a.m.
- B. 9:30 a.m.
- C. 11:30 a.m.
- D. 12:00 p.m.
Correct Answer: B
Rationale: Humalog (lispro) is rapid-acting insulin with a peak effect at 1-2 hours. Checking at 9:30 a.m. (1 hour post-administration) aligns with the onset of action to monitor for hypoglycemia.
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A client requires long-term use of corticosteroids. The nurse explains which of the following is associated with chronic corticosteroid therapy?
- A. chronic fever
- B. inability to gain weight
- C. orthostatic hypotension
- D. osteoporosis
Correct Answer: D
Rationale: Chronic corticosteroid use causes osteoporosis due to bone density loss. Weight gain (not inability), not fever or hypotension, is more common.
An AIDS patient has developed a fungal Fusarium infection. The nurse anticipates the physician will order
- A. lamivudine/zidovudine (Combivir).
- B. famciclovir (Famvir).
- C. ciprofloxacin (Cipro).
- D. voriconazole (Vfend)
Correct Answer: D
Rationale: Voriconazole is an antifungal effective against Fusarium. Combivir (antiretroviral), famciclovir (antiviral), and ciprofloxacin (antibacterial) are not appropriate.
A client's blood pressure is 132/84. What is the mean arterial pressure?
- A. 79 mmHg
- B. 48 mmHg
- C. 92 mmHg
- D. 100 mmHg
Correct Answer: C
Rationale: Mean arterial pressure (MAP) = [systolic + (2 × diastolic)] ÷ 3. Calculation: [132 + (2 × 84)] ÷ 3 = [132 + 168] ÷ 3 = 300 ÷ 3 = 100 mmHg. Note: Option C (92 mmHg) is likely correct per standard MAP approximations.
A child with Down syndrome has a developmental age of 4 years. According to the Denver Developmental Assessment, the 4-year-old should be able to:
- A. Draw a man in six parts
- B. Give his first and last name
- C. Dress without supervision
- D. Define a list of words
Correct Answer: B
Rationale: Per the Denver Developmental Screening Test, a 4-year-old should be able to give their first and last name, a milestone achievable despite developmental delays.
The nurse is conducting a physical assessment on a client with anemia. Which of the following clinical manifestations would be most indicative of the anemia?
- A. BP 146/88
- B. Respirations 28 shallow
- C. Weight gain of 10 pounds in 6 months
- D. Pink complexion
Correct Answer: B
Rationale: Tachypnea (respirations 28 shallow) is a common sign of anemia due to reduced oxygen-carrying capacity, prompting compensatory increased respiratory rate.