Nokea
The nurse is caring for a client scheduled for surgery who is nothing by mouth (NPO) status. Which of the following prescription should the nurse clarify with the primary healthcare physician (PHCP)?
- A. Lispro insulin 5 units SubQ TID
- B. Glargine insulin 15 units SubQ QHS
- C. Vitamin B12 100 mcg IM Daily
- D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days
Correct Answer: A
Rationale: Lispro insulin is a rapid-acting insulin typically administered around mealtimes to manage postprandial glucose levels. Since the client is NPO, they are not eating, so administering lispro insulin could lead to hypoglycemia due to the absence of carbohydrate intake. The nurse should clarify this prescription with the PHCP to ensure safe management of the client’s blood glucose levels during the NPO period. Glargine insulin, a long-acting insulin, is appropriate for basal glucose control and does not require clarification. Vitamin B12 and clonidine are unrelated to food intake and safe for NPO status.
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The nurse is caring for a client with an indwelling urethral catheter. Which of the following actions should the nurse take? Select all that apply.
- A. Empty drainage bag when 1/2 full.
- B. Provide perineal hygiene using mild soap and hot water.
- C. Ensure tubing is clipped onto the edge of the linens.
- D. Wear sterile gloves while cleaning the urinary meatus.
- E. Clean catheter starting at meatus and moving downward while holding it securely.
Correct Answer: A,E
Rationale: Emptying the bag when half full prevents reflux, and cleaning from the meatus downward avoids contamination. Hot water is too harsh, clipping tubing risks tension, and clean gloves suffice for cleaning.
The nurse is discussing infection control practices in the nursing unit. Which client requires droplet precautions? A client with Select all that apply.
- A. Diagnosed with rubella.
- B. A new diagnosis of pharyngeal diphtheria.
- C. Receiving chemotherapy via an implanted port.
- D. Pulmonary tuberculosis receiving nebulizer treatments.
- E. A skin abscess that tested positive for Klebsiella.
Correct Answer: A,B
Rationale: Rubella and pharyngeal diphtheria require droplet precautions due to respiratory transmission. TB requires airborne, chemotherapy does not require isolation, and Klebsiella abscess requires contact precautions.
The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement?
- A. Standard
- B. Droplet
- C. Contact
- D. Airborne
Correct Answer: A
Rationale: Erythema infectiosum is typically non-infectious once the rash appears, requiring only standard precautions.
The nurse prepares to insert a peripheral vascular access device (PVAD) in the client's cephalic vein. The nurse plans to align the catheter how many degrees above the targeted vein?
- A. 10-30 degrees
- B. 30-45 degrees
- C. 45-90 degrees
- D. 45-60 degrees
Correct Answer: A
Rationale: A 10-30 degree angle is optimal for PVAD insertion to enter the vein without piercing through it. Higher angles increase the risk of vein perforation or improper placement.
The nurse is reviewing the assessment findings of a 5-year-old child. The nurse recognizes which vital sign is not within normal limits?
- A. Pulse 73
- B. Blood pressure 90/60 mmHg
- C. Respiratory rate 24
- D. Temperature 98.6°F (37°C)
Correct Answer: C
Rationale: A pulse of 5 is abnormally low for a 5-year-old (normal 70-120). BP 110/60, RR 24, and temperature 37°C are within normal limits.