Nokea
The nurse is caring for a 74-year-old man with type I diabetes. The client is scheduled for cataract surgery under general anesthesia at 9 AM. The man usually receives 30 units of NPH and 10 units of regular insulin each morning at 7 AM. At 7 AM the morning of surgery, the nurse would expect to take which of the following actions?
- A. hold the morning dose of NPH and regular insulin and monitor the blood glucose.
- B. give half the morning dose of NPH insulin along with the regular insulin and monitor the blood glucose when the client returns from surgery.
- C. give the full dose of NPH and regular insulin and monitor the blood glucose every 2 to 4 hours.
- D. give the full dose of regular insulin but hold the NPH insulin and monitor the blood glucose until the client goes to surgery.
Correct Answer: A
Rationale: usually use sliding scale with regular insulin based on blood glucose readings
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A 5-year-old boy is brought to the emergency room after ingesting a bottle of baby aspirin. The nurse should observe the boy for which of the following signs and symptoms?
- A. Nausea and vertigo.
- B. Epistaxis and paralysis.
- C. Dysrhythmia and hypoventilation.
- D. Tinnitus and gastric distress.
Correct Answer: D
Rationale: symptoms of overdose
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate
The nurse is obtaining a health history on a client in the medical clinic. The client states, 'I think I have an ulcer.' Which of the following responses by the nurse is BEST?
- A. Do you have a burning pain in the epigastric region?
- B. Do you have sharp pain in your lower abdomen?
- C. Do you have right shoulder pain with vomiting?
- D. Do you have heartburn when you lie down?
Correct Answer: A
Rationale: Burning epigastric pain is a classic ulcer symptom, guiding further assessment. Options B, C, and D suggest other conditions.
The nurse is caring for a schizophrenic client who has become increasingly withdrawn to the point of mutism. The MOST important nursing approach at this time would be to
- A. ignore the client until he is ready to respond.
- B. sit with the client for brief periods of time.
- C. read to the client in a quiet area of the unit.
- D. encourage the client to play dominos with the group.
Correct Answer: B
Rationale: nurse should maintain contact with client but not make demands to communicate or participate in activities
A three-month-old is placed in Bryant's traction for developmental dysplasia of the hips. Which of the following toys would be appropriate for the nurse to offer the infant during hospitalization?
- A. A rattle.
- B. A stuffed animal.
- C. Colorful blocks.
- D. A tape playing nursery rhymes.
Correct Answer: A
Rationale: three-month-old can grasp a rattle