Nokea
The nurse is preparing to administer insulin to a client with type I diabetes.
- A. Which action should the nurse take first before administering insulin to a client with type I diabetes?
- B. Verify the insulin dose with another nurse.
- C. Check the client’s blood glucose level.
- D. Cleanse the injection site with alcohol.
- E. Rotate the injection site from the previous dose.
Correct Answer: B
Rationale: Checking the client’s blood glucose level is the first step to ensure the insulin dose is appropriate, preventing hypo- or hyperglycemia. Verifying the dose, cleansing the site, and rotating sites are important but follow glucose confirmation.
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A client reports that he has been vomiting for three days, has a low-grade temperature, and feels lethargic. Which of the following nursing actions is MOST appropriate in evaluating for fluid volume deficit?
- A. Obtain a urinalysis for casts and specific gravity.
- B. Determine client's weight and assess gain or loss.
- C. Ask client to provide a 24-hour intake and output record.
- D. Determine the quality of the client's skin turgor.
Correct Answer: B
Rationale: daily weight is the best way to evaluate for fluid volume deficit
When assessing orientation to person, place, and time for an elderly hospitalized client, which of the following principles should be understood by the nurse?
- A. Short-term memory is more efficient than long-term memory.
- B. The stress of an unfamiliar environment may cause confusion.
- C. A decline in mental status is a normal part of aging.
- D. Learning ability is reduced during hospitalization of the elderly client.
Correct Answer: B
Rationale: stress of an unfamiliar situation or environment may lead to confusion in elderly clients
A client is transferred to the neurology unit after developing right-sided paralysis and aphasia. Which of the following should be included in the patient's plan of care?
- A. Encourage client to shake head in response to questions.
- B. Speak in a loud voice during interactions.
- C. Speak using phrases and short sentences.
- D. Encourage the use of radio to stimulate the client.
Correct Answer: C
Rationale: will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions
The nurse is caring for a client with Cushing's syndrome. Which of the following nursing actions would be of HIGHEST priority?
- A. Implement measures to prevent skin breakdown.
- B. Plan measures to prevent infections.
- C. Teach the client signs and symptoms of hyperglycemia.
- D. Instigate measures to prevent fluid overload.
Correct Answer: D
Rationale: respirations are the first priority; clients with Cushing's syndrome are prone to fluid overload and CHF due to sodium and water retention
An elderly alcoholic client has been receiving a long-acting benzodiazepine (Librium) for two days for symptom management and reduction. The client states: 'Get those bugs off of me and clean them out of here.'
The nurse knows the client is exhibiting symptoms of
- A. a reaction to the sedative medication.
- B. a worsening course of the withdrawal syndrome.
- C. an exacerbation of the schizophrenia process.
- D. the process of aging and the effects of delirium.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) client has been medicated with benzodiazepines and did not experience untoward reactions (2) correct-client has most probably progressed to another level of abstinence withdrawal from polypharmacy chemical dependence; characteristic symptoms include tremors, increased heart rate, and fever, as well as psychological problems of confusion, delusions, and hallucinations (3) schizophrenic client usually experiences an episode of auditory hallucinations, not visual or tactile hallucinations (4) combination effect of the normal aging process and dementia could precipitate a similar reaction; however, the normal aging process does not produce delirium, but rather dementia