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The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?
- A. Never use abdominal site for a rotation site.
- B. Pinch the skin up to form a subcutaneous pocket.
- C. Avoid applying pressure after injection.
- D. Change needles after injection.
Correct Answer: B
Rationale: Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. Massaging the site of injection facilitates absorption of the insulin. Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3-7 days.
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A client is admitted with sickle cell crises and sequestration. Upon assessing the client, the nurse would expect to find:
- A. Decreased blood pressure
- B. Moist mucus membranes
- C. Decreased respirations
- D. Increased blood pressure
Correct Answer: A
Rationale: Sickle cell crisis with sequestration can lead to hypovolemia due to blood pooling in organs, resulting in decreased blood pressure.
The nurse is caring for a client with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the nurse's best action?
- A. Notify the physician.
- B. Record the reading as the only action.
- C. Turn the client and recheck the reading.
- D. Place the client supine.
Correct Answer: A
Rationale: An ICP of 66 mmHg is dangerously high (normal <20 mmHg), requiring immediate physician notification for intervention. Recording only (B), turning (C), or supine positioning (D) delays critical action.
A five-month-old infant is admitted to the ER with a temperature of 103.6°F and irritability. The mother states that the child has been listless for the past several hours and that he had a seizure on the way to the hospital. A lumbar puncture confirms a diagnosis of bacterial meningitis. The nurse should assess the infant for:
- A. Periorbital edema
- B. Tenseness of the anterior fontanel
- C. Positive Babinski reflex
- D. Negative scarf sign
Correct Answer: B
Rationale: Tenseness of the anterior fontanel indicates increased intracranial pressure in bacterial meningitis due to inflammation. The other findings are not specific to meningitis in infants.
The nurse is caring for a client with a diagnosis of chorioamnionitis. Which intervention is most appropriate?
- A. Administer antibiotics
- B. Monitor fetal heart tones
- C. Prepare for delivery
- D. All of the above
Correct Answer: D
Rationale: Chorioamnionitis requires antibiotics for infection fetal heart tone monitoring for distress and preparation for delivery (vaginal or cesarean) if maternal or fetal condition worsens. All interventions are appropriate.
A client with a renal failure is prescribed a low potassium diet. Which food choice would be best for this client?
- A. 1 cup beef broth
- B. 1 baked potato with the skin
- C. 1/2 cup raisins
- D. 1 cup rice
Correct Answer: D
Rationale: A low potassium diet is essential for clients with renal failure to prevent hyperkalemia. Among the options, 1 cup of rice has the lowest potassium content (approximately 50–100 mg per cup), making it the best choice. Beef broth contains moderate potassium (around 200 mg per cup), a baked potato with skin is high in potassium (about 900 mg), and raisins are also high (around 500 mg per half cup).