Nokea
Laboratory reference ranges
Glucose (random)
71-200 mg/dL
(3.9–11.1 mmol/L)
The nurse is caring for assigned clients. Which of the following clients should the nurse check first?
- A. client who had a cholecystectomy and is reporting incisional pain as 5 on a scale of 1-10
- B. client who had an open reduction of the right femur and is reporting nausea
- C. client with type 1 diabetes mellitus and a blood glucose level of 55 mg/dL (3.1 mmol/L)
- D. client with type 2 diabetes mellitus and a blood glucose level of 250 mg/dL (13.9 mmol/L)
Correct Answer: C
Rationale: A blood glucose level of 55 mg/dL indicates severe hypoglycemia, a life-threatening condition requiring immediate intervention to prevent seizures or coma.
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A student nurse is preparing to administer the hepatitis B vaccine to a newborn. Which statement by the student nurse requires the preceptor to provide further teaching?
- A. A 5/8-inch, 25-gauge needle is appropriate for intramuscular injection in newborns.
- B. I will clean the injection site with an antiseptic swab before administration.
- C. I will draw the medication into a 1-mL syringe.
- D. The medication should be administered into the deltoid muscle.
Correct Answer: D
Rationale: The deltoid muscle is not developed enough in newborns for intramuscular injections. The hepatitis B vaccine should be administered in the anterolateral thigh.
Laboratory reference ranges
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L)
The nurse is assisting with the care of four clients with diabetes mellitus. Which of the following prescriptions should the nurse clarify with the health care provider?
- A. 10 units regular insulin IV push for serum glucose level >250 mg/dL (13.9 mmol/L)
- B. 14 units glargine insulin subcutaneous injection every night at 2000
- C. 18 units aspart insulin subcutaneous injection 15 minutes before breakfast
- D. 20 units NPH insulin IV push administered every morning at 700
Correct Answer: D
Rationale: NPH insulin is not administered IV, as it is a suspension and can cause embolism or erratic absorption. This prescription requires clarification.
The practical nurse is collecting data on a client receiving methotrexate to treat rheumatoid arthritis. Which finding associated with this drug is most important for the nurse to report to the registered nurse?
- A. Hair loss
- B. Nausea
- C. Petechiae
- D. Stomatitis
Correct Answer: C
Rationale: Petechiae indicate thrombocytopenia, a serious adverse effect of methotrexate, risking bleeding and requiring immediate reporting for dose adjustment or discontinuation.
The nurse is assigning client care tasks to unlicensed assistive personnel. Which statement by the nurse is appropriate?
- A. I need you to take vital signs on all clients in rooms 1 through 10 this morning
- B. Mrs. Jones fell out of bed during the night while walking to the commode. Please monitor her closely.
- C. Please ensure that Mr. Garcia in room 8 ambulates several times.
- D. Please take Mr. Wu's vital signs in 10 minutes and let me know if his systolic blood pressure is <100.
Correct Answer: A
Rationale: Assigning vital signs for multiple clients is clear, specific, and within the UAP's scope of practice, ensuring safe delegation.
An adult client is receiving oxygen at 6 L/min. The client asks the nurse why the oxygen is running through bubbling water. What should be included in the nurse's reply?
- A. The water cools the oxygen and makes it more comfortable.
- B. Oxygen is very drying to tissues; the water humidifies it.
- C. The water prevents fires when oxygen is in use.
- D. The water helps to prevent infections from developing in the tubing.
Correct Answer: B
Rationale: Bubbling water in oxygen delivery systems humidifies the oxygen, preventing mucosal drying. It doesn't cool oxygen, prevent fires, or reduce infections.