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The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin lispro (Humalog) 8 units before meals. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Sweating and confusion.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Sweating and confusion indicate hypoglycemia, a medical emergency with insulin lispro. Options A, C, and D are less urgent.
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The nurse is caring for a client with a new colostomy.
- A. What is the most appropriate teaching point for a client with a new colostomy?
- B. Change the appliance every morning.
- C. Empty the pouch when it is one-third full.
- D. Use a mild soap to cleanse the peristomal skin.
- E. Apply a skin barrier only if irritation occurs.
Correct Answer: C
Rationale: Using a mild soap to cleanse the peristomal skin prevents irritation and maintains skin integrity. Changing the appliance daily is unnecessary, emptying at one-third full prevents leaks, and a skin barrier should be used routinely to protect the skin.
The nurse is caring for a client with a history of dementia.
- A. Which intervention is most effective for communicating with a client with dementia?
- B. Speak loudly to ensure understanding.
- C. Use simple, clear sentences.
- D. Ask open-ended questions.
- E. Provide written instructions.
Correct Answer: B
Rationale: Using simple, clear sentences enhances comprehension in dementia patients with cognitive impairment. Loud speaking is unnecessary, open-ended questions overwhelm, and written instructions are ineffective.
The nurse is caring for a client with a history of atrial fibrillation who is receiving digoxin (Lanoxin) 0.125 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 3.0 mEq/L.
- B. Sodium 140 mEq/L.
- C. Magnesium 2.0 mEq/L.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hypokalemia (potassium 3.0 mEq/L) increases the risk of digoxin toxicity, which can cause life-threatening arrhythmias in atrial fibrillation. Options B, C, and D are normal: sodium 140 mEq/L, magnesium 2.0 mEq/L, and calcium 9.0 mg/dL do not affect digoxin.
A 3 year-old had a hip spica cast applied two hours ago. In order to facilitate drying, the nurse should
- A. Expose the cast to air and turn the child frequently
- B. Use a heat lamp to reduce the drying time
- C. Handle the cast with the abductor bar
- D. Turn the child as little as possible
Correct Answer: A
Rationale: Expose the cast to air and turn the child frequently. The child should be turned every two hours, with the cast's surface exposed to the air.
An adult male had a myocardial infarction six weeks ago. He asks the nurse if it is safe for him to have sex. What should the nurse include when replying?
- A. Taking nitroglycerin before sexual activity is often helpful.
- B. Taking drugs for erectile dysfunction in addition to nitroglycerin is advised.
- C. The client should rest for several hours before engaging in sexual activity.
- D. Sexual activity should be avoided for six months after a heart attack.
Correct Answer: A
Rationale: Nitroglycerin before sexual activity can prevent angina, and sexual activity is generally safe 6 weeks post-MI if the patient is stable.