The nurse is caring for a client who had a total abdominal h...

The nurse is caring for a client who had a total abdominal hysterectomy 2 days ago. The client reports hearing music coming from the television, which is turned off. Which of the following actions should the nurse take first?

A. Ask the client when the auditory hallucinations began
B. Check the client’s medication administration record
C. Obtain a set of vital signs including temperature
D. Turn on the television to see if the music stops

Correct Answer: B

Rationale: Checking the medication record identifies potential causes of hallucinations, such as opioids or anesthetics. Timing, vital signs, and TV checks are secondary to ruling out medication effects.

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The nurse is discussing activities for parallel play with the parents of a 2-year-old child. Which of the following activities are appropriate suggestions for this type of play? Select all that apply.

A. Digging in a sandbox
B. Finger painting
C. Playing a board game
D. Playing soccer
E. Pushing toy cars

Correct Answer: A,B,E

Rationale: Parallel play involves independent activities side-by-side, like digging, painting, or pushing cars. Board games and soccer require cooperative play, unsuitable for 2-year-olds.

Laboratory reference ranges
Glucose (fasting)
70–110 mg/dL
(3.9–6.1 mmol/L)

The nurse is caring for a client who has acute pancreatitis. Which of the following findings is most concerning?

A. Serum glucose levels for the past 24 hours are ≥250 mg/dL (13.9 mmol/L)
B. Client is lying with knees drawn up to the abdomen to alleviate pain
C. Temperature is 102.2°F (39°C) with increasing abdominal pain
D. Five large, liquid stools are yellow and foul-smelling

Correct Answer: C

Rationale: Fever (102.2°F) with increasing abdominal pain suggests infection or abscess, a life-threatening complication of pancreatitis. Hyperglycemia, knee-flexed positioning, and diarrhea are concerning but less urgent.

A client diagnosed with stable angina is being discharged home on the cholesterol-lowering drug rosuvastatin. The nurse should reinforce the need to report which symptom?

A. Abdominal discomfort
B. Insomnia
C. Morning headache
D. Muscle aches or weakness

Correct Answer: D

Rationale: Muscle aches or weakness may indicate myopathy or rhabdomyolysis, serious rosuvastatin side effects. Abdominal discomfort, insomnia, and headaches are less specific.

Medication administration record
Allergies: No known allergies
Sliding-Scale Serum Glucose Level Regular Insulin Dose
<150 mg/dL (<8.3 mmol/L) 0 units
150-199 mg/dL (8.3-11 mmol/L) 3 units
200-249 mg/dL (11.1-13.8 mmol/L) 5 units
250-299 mg/dL (13.9-16.6 mmol/L) 7 units
≥300 mg/dL (≥16.7 mmol/L) 9 units and notify the health care provider

The nurse is caring for a client who has a prescription for 25 units of NPH insulin and sliding-scale regular insulin. The client's serum glucose level is 237 mg/dL (13.2 mmol/L). How many total units of insulin should the nurse administer to the client? Record your answer using a whole number.

Correct Answer: 29

Rationale: Assuming a sliding-scale protocol (e.g., 4 units for 201-250 mg/dL), 25 units NPH + 4 units regular = 29 units total.

The nurse is performing a neurological assessment on a client post right cerebral vascular accident (CVA). Which finding, if observed by the nurse, would warrant immediate attention?

A. Decrease in level of consciousness
B. Loss of bladder control
C. Altered sensation of stimuli
D. Emotional lability

Correct Answer: A

Rationale: Decrease in level of consciousness. A further decrease in the level of consciousness would be indicative of a further progression of the CVA.