Nokea
The nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare to absorption at other sites?
- A. Insulin is absorbed more slowly at abdominal injection sites than at other sites.
- B. Insulin absorbed rapidly regardless of the injection site.
- C. Insulin is absorbed more rapidly at abdominal injection than at other sites.
- D. Insulin is absorbed unpredictably at all injection sites.
Correct Answer: C
Rationale: Rationale:
1. Abdominal injection sites have a higher blood supply, leading to faster absorption.
2. Insulin absorption is faster in areas with more blood vessels.
3. Rapid absorption at the abdomen results in quicker onset of action.
4. Other sites may have slower absorption due to less blood flow.
Summary:
A: Incorrect. Absorption is faster at abdominal sites due to increased blood flow.
B: Incorrect. Absorption varies based on injection site blood supply.
C: Correct. Abdominal injection sites have rapid insulin absorption.
D: Incorrect. Insulin absorption is consistent based on blood flow at injection sites.
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A patient has iron deficiency anemia. Which of the following foods will best help provide dietary iron?
- A. Fresh fruits
- B. Dairy products
- C. Lean red meats
- D. Breads and cereals
Correct Answer: C
Rationale: The correct answer is C: Lean red meats. Lean red meats are a rich source of heme iron, which is more easily absorbed by the body compared to non-heme iron found in plant-based foods. Heme iron helps improve iron levels more effectively in individuals with iron deficiency anemia. Fresh fruits (A) and dairy products (B) contain minimal iron, while breads and cereals (D) provide non-heme iron which is not as readily absorbed.
A client complains of sporadic epigastric pain, yellow skin, nausea, vomiting, weight loss, and fatigue. Suspecting gallbladder disease, the physician orders a diagnostic workup, which reveals gallbladder cancer. Which nursing diagnosis may be appropriate for this client?
- A. Anticipatory grieving
- B. Disturbed body image
- C. Impaired swallowing
- D. Chronic low self-esteem
Correct Answer: A
Rationale: The correct answer is A: Anticipatory grieving. This nursing diagnosis is appropriate because the client's symptoms, such as weight loss, fatigue, and diagnosis of gallbladder cancer, indicate a serious health condition that may lead to emotional distress. Anticipatory grieving involves feelings of loss and sadness related to an anticipated loss, such as the diagnosis of cancer. The client may experience fear, anxiety, and sadness due to the potential impact of the illness on their life.
Choice B (Disturbed body image) is incorrect because the client's symptoms are more indicative of a serious health concern rather than body image issues. Choice C (Impaired swallowing) is incorrect as the symptoms described do not suggest difficulty with swallowing. Choice D (Chronic low self-esteem) is also incorrect as the symptoms are more likely related to physical health issues rather than self-esteem concerns.
A nurse is using the problem-oriented approach to data collection. Which action will the nurse take first?
- A. Complete the questions in chronological order.
- B. Focus on the patient’s presenting situation.
- C. Make accurate interpretations of the data.
- D. Conduct an observational overview.
Correct Answer: B
Rationale: The correct answer is B: Focus on the patient's presenting situation. This is the first step in the problem-oriented approach as it helps the nurse understand the immediate issues and prioritize data collection. By focusing on the presenting situation, the nurse can gather relevant information efficiently.
A: Completing questions in chronological order may not address the current problem effectively.
C: Making accurate interpretations of the data comes after data collection, not as the first step.
D: Conducting an observational overview is important but typically follows focusing on the presenting situation to guide what observations are necessary.
Nurse Lina gives discharge instructions to Aling Maria, who is experiencing an exacerbation of COPD because of an upper respiratory tract infection, regarding her diet at home. Which of the following food choices would be appropriate?
- A. low fat low cholesterol
- B. low sodium diet
- C. bland soft diet
- D. high calorie high protein
Correct Answer: D
Rationale: The correct answer is D: high calorie high protein. In COPD exacerbation, the body requires extra calories and protein for energy and muscle strength. High-calorie foods help combat weight loss and fatigue. High-protein foods aid in muscle repair and maintenance. Low-fat low-cholesterol (A) is not ideal as healthy fats are needed. Low-sodium (B) is not necessary unless there is concurrent heart failure. Bland soft diet (C) is not suitable as it does not provide enough calories and protein needed for COPD exacerbation.
A client with colon cancer requires a permanent colostomy because of the tumor location. After surgery, the client must learn how to irrigate the colostomy. When irrigating, how far into the stoma should the client insert the lubricated catheter?
- A. 0.25” to 0.5”
- B. 2” to 4”
- C. 1” to 1.5”
- D. 5” to 7”
Correct Answer: C
Rationale: The correct answer is C: 1” to 1.5”. When irrigating a colostomy, the client should insert the lubricated catheter about 1” to 1.5” into the stoma. This depth allows for effective irrigation of the colon without causing discomfort or damage. Inserting the catheter too shallow (choice A) may not reach the colon, while inserting it too deep (choices B and D) can cause injury or perforation. Therefore, the optimal depth of 1” to 1.5” ensures proper irrigation while minimizing risks of complications.