Nokea
The nurse is caring for a client who has a prescription for insulin lispro 1 unit subcutaneously per 15 g of carbohydrates with each meal. The client's meal contains 75 g of carbohydrates. How many units of insulin lispro should the nurse administer to the client? Record your answer using a whole number.
Correct Answer: 5
Rationale: 75 g carbohydrates ÷ 15 g/unit = 5 units of insulin lispro.
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An adult is taking phenazopyridine hydrochloride (Pyridium) 200 mg PO tid after meals. Which comment by the client indicates a lack of understanding about the medication?
- A. If I take my medications after meals, I avoid upsetting my stomach.'
- B. I am concerned that my urine is bright orange.'
- C. I do not have as great an urge to urinate since I have been on Pyridium.'
- D. I have to let my doctor know if my skin or eyes turn yellow.'
Correct Answer: B
Rationale: Bright orange urine is a normal effect of Pyridium, so concern about it indicates a lack of understanding of the medication's side effects.
A mother has brought her 9-month-old baby to the physician's office for a well baby visit. Based on knowledge of normal growth and development, the nurse would expect that the ability the child has acquired most recently is which of the following?
- A. Sitting up unsupported
- B. Rolling over without help
- C. Holding head up without assistance
- D. Smiling in response to a familiar face
Correct Answer: A
Rationale: By 9 months, sitting unsupported is a recently acquired milestone, typically achieved around 6-8 months, following earlier skills like rolling over and head control.
A client is 2 days post operative. The vital signs are: BP - 120/70, HR - 110 BPM, RR - 26, and Temperature - 100.4 degrees Fahrenheit (38 degrees Celsius). The client suddenly becomes profoundly short of breath, skin color is gray. Which assessment would have alerted the nurse first to the client's change in condition?
- A. Heart rate
- B. Respiratory rate
- C. Blood pressure
- D. Temperature
Correct Answer: B
Rationale: Tachypnea is one of the first clues that the client is not oxygenating appropriately. The compensatory mechanism for decreased oxygenation is increased respiratory rate.
The nurse is experiencing repeated unwanted sexual advances from a health care provider (HCP). Which of the following actions should the nurse take? Select all that apply.
- A. Seek emotional support from a trusted source.
- B. Consult the facility's sexual harassment policy.
- C. Report the behavior to the supervisor immediately.
- D. Document each occurrence according to facility policy.
- E. Confront the HCP outside the workplace about the behavior.
Correct Answer: A,B,C,D
Rationale: Seeking support aids coping, reviewing policy clarifies procedures, reporting to a supervisor initiates formal action, and documentation provides evidence. Confronting outside work risks escalation and is unsafe.
The nurse is caring for a client with Kawasaki disease. Which of the following actions would be a priority for the nurse to take?
- A. Monitor the client for gallop heart sounds and decreased urine output.
- B. Provide a quiet, nonstimulating, restful environment for the client.
- C. Apply cool compresses to the skin of the client's hands and feet.
- D. Offer the client soft foods and adequate amounts of clear liquids.
Correct Answer: B
Rationale: A quiet, restful environment reduces irritability and stress in Kawasaki disease, promoting recovery. Monitoring heart sounds/urine output is secondary, as cardiac complications are less immediate. Cool compresses and soft foods are less critical.