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The nurse is caring for a client who has a prescribed regular insulin sliding scale. At 0800, the client's capillary blood glucose (CBG) was 258 mg/dl (14.29 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1215 the CBG was 288 mg/dl (15.984 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. At 1730 the CBG was 254 mg/dI (14.097 mmol/L) [70-110 mg/dL, 4.0-11.0 mmol/L]. The nurse should do which of the following at 1730?
- A. Administer 8 units of regular insulin
- B. Administer 6 units of regular insulin
- C. Notify the primary health care provider (PHCP)
- D. Withhold the prescribed insulin
- E. Modify the client's prescribed diet to low sodium
Correct Answer: B,C
Rationale: Per the sliding scale, 254 mg/dL requires 6 units of insulin, and three consecutive CBGs >250 mg/dL require notifying the PHCP.
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The nurse is teaching parents about fire safety in the home. Which of the following recommendations should the nurse make? Select all that apply.
- A. Use smoke detectors instead of carbon monoxide detectors
- B. Teach your child what the smoke detector sounds like and what to do when one is heard
- C. Teach children how to light a candle in the event of power failure
- D. Practice escaping from your home at least twice a year
- E. Ensure that electrical wiring is under rugs, not above them
- F. If a house fire occurs, call emergency services before evacuating
Correct Answer: B,D
Rationale: Teaching children about smoke detector sounds and escape actions, and practicing escape plans twice yearly, enhance fire safety. Both types of detectors are needed, candles pose risks, wiring under rugs is hazardous, and evacuation precedes calling services.
The nurse is planning care for a pediatric client being admitted with pulmonary tuberculosis (TB). Which of the following interventions should the nurse include in the client's plan of care?
- A. consult the infection control nurse
- B. room the client with an uninfected client 6 feet apart
- C. place the client with another client who has varicella in the shared airborne isolation room 6 feet apart
- D. place the client in a private room with monitored positive airflow
Correct Answer: A
Rationale: Consulting the infection control nurse ensures proper airborne precautions for TB. Cohorting or positive airflow is inappropriate.
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 4 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
For each potential intervention, click to specify whether the intervention is indicated or not indicated for the client with progressive multiple sclerosis.
- A. Obtain a referral for occupational therapy for fatigue and energy conservation training
- B. Promote rest by encouraging daytime napping over consistent nighttime sleep
- C. Encourage the client to walk to the mailbox at midday for sun exposure
- D. Instruct the client to increase fluid intake with caffeinated beverages
- E. Obtain an order for physical therapy for home mobility and coordination evaluation
- F. Educate the client on the early signs of cystitis and the importance of completing antibiotics
- G. Educate the client to wear slippers while walking inside
Correct Answer: A,E,F,G
Rationale: Occupational therapy, physical therapy, cystitis education, and slipper use are indicated to address fatigue, mobility, infection prevention, and fall risk. Daytime napping and midday sun exposure are not indicated due to heat sensitivity and inconsistent sleep.
The nurse is teaching at an interdisciplinary conference focused on age-related changes. Which of the following are expected in the older adult? Select all that apply.
- A. Fatty tissue is redistributed
- B. Skin becomes less elastic
- C. Cardiac output increases
- D. Muscle mass increases
- E. Hormone production increases
- F. Visual and hearing acuity diminishes
Correct Answer: A,B,F
Rationale: Aging involves fat redistribution, less elastic skin, and diminished sensory acuity. Cardiac output, muscle mass, and hormone production decrease.
The nurse works on a medical-surgical unit and is responsible for assessing the client's vital signs. Which of the following clients can have their temperature measured orally? Select all that apply.
- A. A 61-year-old woman who had oral surgery
- B. A 44-year old man with chest pain on oxygen via nasal canula
- C. An 83-year-old woman with diarrhea
- D. A 29-year-old client with an earache
- E. A 6-year-old client with a sore throat and difficulty swallowing
Correct Answer: B,C,D
Rationale: Oral temperature is safe for clients with chest pain, diarrhea, or earache, as they have no oral contraindications. Oral surgery and difficulty swallowing contraindicate oral measurement.