Nokea
The nurse is preparing to administer insulin aspart subcutaneously at 0700 to a client with type 1 diabetes mellitus. Which of following actions would be a priority for the nurse to take?
- A. Choose a site on the clients arm for the injection
- B. Give the client breakfast within 15 minutes
- C. Recheck the capillary blood glucose level in 1 hour
- D. Reinforce teaching about signs and symptoms of hyperglycemia
Correct Answer: B
Rationale: Insulin aspart is rapid-acting, peaking within 1-3 hours. Administering it at 0700 requires breakfast within 15 minutes to prevent hypoglycemia. Site selection is routine, rechecking glucose later is secondary, and teaching is not urgent.
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The practical nurse is collaborating with the registered nurse to admit a client who will receive general anesthesia in the same-day surgery unit. The client has never had surgery before. Which question is most critical for the nurse to ask the client during preoperative assessment and health history taking?
- A. Has any family member ever had a bad reaction to general anesthesia?
- B. Have you ever experienced low back pain?
- C. Have you ever had an anaphylactic reaction to a bee sting?
- D. Have you ever received opioid pain medications?
Correct Answer: A
Rationale: A family history of adverse reactions to anesthesia (e.g., malignant hyperthermia) is critical, as it's a potentially fatal genetic condition. Other questions are less urgent for anesthesia safety.
The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply.
- A. Dim lights to prevent overstimulation
- B. Directly face the client when speaking
- C. Ensure hearing aids are properly applied
- D. Provide written information to supplement conversation
- E. Raise voice to speak loudly to the client
Correct Answer: B,C,D
Rationale: Facing the client aids lip-reading, properly applied hearing aids optimize hearing, and written information reinforces verbal communication. Dimming lights may hinder lip-reading, and shouting distorts speech.
The nurse is caring for a client with HIV. The nurse understands that which of the following are true regarding transmission-based precautions? Select all that apply.
- A. Donning an N95 respiratory mask decreases the risk of transmitting HIV
- B. Gown, gloves, and face shield are necessary for every client encounter
- C. Neutropenic precautions are implemented based on laboratory results
- D. The client's urine is a bodily fluid that can transmit HIV
- E. The nurse should perform hand hygiene before and after providing client care
Correct Answer: C,D,E
Rationale: Neutropenic precautions depend on lab results (e.g., low white blood cell count). Urine can transmit HIV if blood is present. Hand hygiene is standard for all encounters. N95 masks are for airborne diseases, not HIV. Full PPE isn't needed unless splashing of bodily fluids is likely.
The nurse is reinforcing discharge teaching on a client with polycythemia vera. Which would be included in the teaching plan?
- A. Avoid large crowds.
- B. Keep the head of the bed elevated at night.
- C. Wear socks and gloves when going outside.
- D. Know the signs and symptoms of thrombosis.
Correct Answer: D
Rationale: Polycythemia vera increases blood viscosity, raising the risk of thrombosis. Teaching the client to recognize signs and symptoms of thrombosis, such as swelling or pain in extremities, is critical. Avoiding large crowds relates to infection risk, not thrombosis. Elevating the head of the bed is unrelated, and wearing socks and gloves is more relevant for conditions like Raynaud's.
The nurse is caring for a client with latent pulmonary tuberculosis who has been receiving isoniazid daily for the past 2 months. The client reports numbness and tingling in the hands and feet. The nurse should recognize that the client is likely experiencing a deficiency in
- A. iron
- B. vitamin B6
- C. folic acid
- D. vitamin D3
Correct Answer: B
Rationale: Isoniazid can deplete vitamin B6 (pyridoxine), causing peripheral neuropathy (numbness, tingling). Other deficiencies (iron, folic acid, vitamin D3) don't typically cause neuropathy.