Nokea
The nurse is preparing to administer a dose of regular insulin to a client based on a sliding scale. The client’s blood glucose is 320 mg/dL. The sliding scale orders 6 units of regular insulin for a blood glucose of 301–350 mg/dL. Which of the following actions should the nurse take?
- A. Administer 6 units of regular insulin.
- B. Administer 8 units of regular insulin.
- C. Withhold the insulin and notify the physician.
- D. Recheck the blood glucose in 30 minutes.
Correct Answer: A
Rationale: the sliding scale indicates 6 units for a blood glucose of 320 mg/dL, so the dose is correct
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The client taking Glyburide (Diabeta) should be cautioned to:
- A. Avoid eating sweets
- B. Report changes in urinary pattern
- C. Allow 3 hours for onset
- D. Check the glucose daily
Correct Answer: D
Rationale: Daily glucose monitoring is essential for clients on Glyburide to manage blood sugar levels effectively.
A 2-year-old is hospitalized with suspected intussusception. Which finding is associated with intussusception?
- A. Currant jelly stools
- B. Projectile vomiting
- C. Ribbonlike stools
- D. Palpable mass over the flank
Correct Answer: A
Rationale: Currant jelly stools, caused by blood and mucus, are a hallmark of intussusception due to intestinal obstruction.
The school nurse is teaching a group of preschool mothers about poison prevention in the home. Which of the following statements, if made by a mother to the nurse, indicates that further teaching is necessary?
- A. I should have a bottle of Ipecac for each of my children.
- B. I should induce vomiting if my child swallows lighter fluid.
- C. Giving my child water or milk may help dilute the poison.
- D. Proper storage is the key to poison prevention in the home.
Correct Answer: B
Rationale: vomiting contraindicated when child ingests hydrocarbons due to danger of aspiration
Which one of the following symptoms is common in the client with duodenal ulcers?
- A. Vomiting shortly after eating
- B. Epigastric pain following meals
- C. Frequent bouts of diarrhea
- D. Presence of blood in the stools
Correct Answer: B
Rationale: Duodenal ulcers typically cause epigastric pain 1-3 hours after meals, relieved by food or antacids.
According to Maslow's hierarchy of needs, 'lack of prejudice' falls under which level of human need fulfillment?
- A. love and belonging
- B. self-actualization
- C. safety
- D. esteem
Correct Answer: B
Rationale: Lack of prejudice reflects self-actualization, Maslow’s highest level, where individuals achieve personal growth and acceptance of others.