Nokea
The nurse is teaching a client about self-administration of insulin. Which of the following sites should the nurse recommend for insulin injection?
- A. Forearm.
- B. Upper arm.
- C. Abdomen.
- D. Lower back.
Correct Answer: C
Rationale: the abdomen is a preferred site for insulin injection due to consistent absorption rates
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The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
- A. Encourage child to sleep and decrease stimuli in the room.
- B. Assess orientation to person, place, and time every hour.
- C. Notify the physician regarding a negative Babinski reflex.
- D. Increase fluid intake to maintain adequate urinary output.
Correct Answer: B
Rationale: early signs of increased intracranial pressure are alterations in orientation
A college student was in a motor vehicle accident six months ago. Although he was minimally injured, his friend was killed. The client comes to Student Health Services with complaints of not being able to study, not sleeping, and thinking he's 'going crazy.'
It is MOST important for the nurse to
- A. perform a complete physical and social history.
- B. obtain a complete drug and alcohol history, including reports from a drug screen.
- C. review the significant events of the last year.
- D. explore how he coped with the motor vehicle crash and his friend's death.
Correct Answer: D
Rationale: Strategy: Determine the outcome of each answer choice. (1) not most important initially (2) not most important initially (3) not most important initially (4) correct-initially obtaining focused information about a very traumatic event is helpful and provides the nurse with an opportunity to understand how this client has coped with a tragedy that has made him vulnerable
A patient complains of pain after an appendectomy. After administering an analgesic, the nurse should take which of the following actions?
- A. Elevate the head of the bed 30-45°.
- B. Place a pillow behind the patient's knees.
- C. Elevate the knee gatch on the bed 30°.
- D. Lie the client supine with a small pillow under the head.
Correct Answer: A
Rationale: would reduce stress on suture line and provide for comfort
A 56-year-old woman has a subclavian triple lumen catheter that is used for administration of total parenteral nutrition (TPN). The physician has ordered that all lumens be flushed with a diluted heparin solution BID. When the nurse attempts to flush the distal lumen, resistance is met. The nurse should
- A. clamp off the lumen and label it as 'clotted off.'
- B. gradually increase the pressure on the irrigating solution.
- C. aspirate blood from the lumen to restore patency.
- D. secure the lumen with a Luer-Lock cap and notify the physician.
Correct Answer: D
Rationale: streptokinase may used to dissolve clot, if unsuccessful, lumen is labeled as clotted off
The nurse takes a history from a woman in the prenatal clinic. The nurse identifies that which of the following pregnant women is MOST likely to have an Rh-incompatibility problem?
- A. An Rh-positive woman pregnant for the third time who conceived with an Rh-negative man and never has received RhoGAM.
- B. An Rh-negative woman who conceived with an Rh-positive man who has Rh antibodies.
- C. An Rh-positive woman who previously aborted a fetus at 12 weeks gestation and did not receive RhoGAM and now conceived with an Rh-positive man.
- D. An Rh-negative woman who never received RhoGAM and now conceived with an Rh-negative man.
Correct Answer: B
Rationale: Rh-positive dominant, fetus will be Rh-positive, Rh antibodies from the mother will break down fetus's blood cells