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The nurse is caring for a client with a history of type 1 diabetes who is receiving insulin detemir (Levemir) 15 units SC daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue
- B. Sweating and shakiness
- C. Occasional thirst
- D. Mild headache
Correct Answer: B
Rationale: Sweating and shakiness indicate hypoglycemia, a medical emergency with insulin detemir. Options A, C, and D are less urgent: fatigue is nonspecific, thirst is expected, and headache is common.
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The nurse is performing a post-op assessment of an elderly client with a total hip repair. Although he has not requested medication for pain, the nurse suspects that the client's discomfort is severe and prepares to administer pain medication. Which of the following signs would not support the nurse's assessment of acute post-op pain?
- A. Increased blood pressure
- B. Inability to concentrate
- C. Dilated pupils
- D. Decreased heart rate
Correct Answer: D
Rationale: Acute pain typically increases heart rate, blood pressure, and pupil dilation. Decreased heart rate is not consistent with acute pain.
The homecare nurse is visiting a young adult with a diagnosis of hepatitis A. Which of the following statements, if made by the client to the nurse, indicates that further teaching is needed?
- A. I have been very careful to wash my hands after I go to the bathroom.
- B. I have had to take Tylenol several times this week for this sinus infection I have.
- C. I have been very careful not to handle my child's toys or eating utensils.
- D. My husband has been preparing all of the meals since I've been sick.
Correct Answer: B
Rationale: Tylenol (acetaminophen) is hepatotoxic and should be avoided in hepatitis A, which impairs liver function, indicating a need for further teaching. Options A, C, and D show correct precautions to prevent oral-fecal transmission.
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Continue to monitor the client to see if the bubbling increases
- D. Instruct the client to try to avoid coughing
Correct Answer: C
Rationale: Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.
The nurse is teaching a client how to perform self-monitoring blood glucose (SMBG) using a blood glucose monitor.
Which of the following actions, if performed by the client, indicates to the nurse the need for further teaching?
- A. The client lets her hand dangle before sticking her finger with the lancet.
- B. The client sticks her finger on the side of the distal phalanx.
- C. The client touches the strip with a large drop of blood hanging from her fingertip.
- D. The client milks her finger after sticking it.
Correct Answer: D
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) helps to facilitate venous congestion (2) less painful than the center of the fingertip (3) blood should sit on the strip like a raindrop, smearing alters the reading (4) correct-forces interstitial fluid to mix with capillary blood and dilutes the blood
The nurse is caring for a client with a history of peptic ulcer disease.
- A. Which dietary instruction is most appropriate for a client with peptic ulcer disease?
- B. Avoid spicy foods and caffeine.
- C. Eat large meals three times daily.
- D. Consume high-fat foods to coat the stomach.
- E. Drink alcohol in moderation.
Correct Answer: A
Rationale: Avoiding spicy foods and caffeine reduces gastric irritation in peptic ulcer disease. Small, frequent meals are preferred, high-fat foods delay healing, and alcohol exacerbates ulcers.