Nokea
The nurse is teaching a client how to mix regular and NPH insulins in the same syringe. Which action should the nurse instruct the client to take?
- A. Draw up the NPH insulin into the syringe first.
- B. Keep both bottles in the refrigerator at all times.
- C. Rotate the NPH insulin bottle in the hands before mixing.
- D. Take all of the air out of the insulin bottles before mixing.
Correct Answer: C
Rationale: The NPH insulin bottle needs to be rotated for at least 1 minute between both hands. This resuspends the insulin. The nurse should not shake the bottles. Shaking causes foaming and bubbles to form, which may trap particles of insulin and alter the dosage. Regular insulin is drawn up before NPH insulin. Insulin may be maintained at room temperature. Additional bottles of insulin for future use should be stored in the refrigerator. Air does not need to be removed from the insulin bottles.
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A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, PCO2 31 mm Hg, PaO2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the PCO2 is less than 35, whereas respiratory acidosis is present when the PCO2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.
The nurse is monitoring a client who is receiving a blood transfusion when the client reports diaphoresis, warmth, and a backache. The nurse should take which actions? Select all that apply.
- A. Remove the IV catheter.
- B. Document the occurrence.
- C. Stop the blood transfusion.
- D. Contact the primary health care provider.
- E. Hang 0.9% sodium chloride solution.
Correct Answer: B,C,D,E
Rationale: If a client experiences diaphoresis, warmth, and a backache, a transfusion reaction is suspected. The nurse stops the transfusion and prevents the infusion of any additional blood; then the nurse hangs a bag of 0.9% sodium chloride solution. This maintains IV access and helps maintain the client's intravascular volume. The primary health care provider is notified, as is the blood bank. The nurse also documents the occurrence, the actions taken, and the client's response. To preserve the IV access, the nurse should not remove the catheter and discontinue the IV site.
Which of the following should be a priority nursing diagnosis for a client who has had a total laryngectomy?
- A. Risk for impaired skin integrity.
- B. Excess fluid volume.
- C. Ineffective thermoregulation.
- D. Impaired verbal communication.
Correct Answer: D
Rationale: Impaired verbal communication is the priority after a total laryngectomy due to the loss of vocal cords, affecting communication ability.
A new breast-feeding mother experiencing breast engorgement is provided with instructions regarding care for the condition. Which statement by the mother indicates to the nurse that she possesses an understanding of the measures that will provide comfort for the engorgement?
- A. I will breast-feed using only one breast.
- B. I will apply cold compresses to my breasts.
- C. I will avoid the use of a bra while my breasts are engorged.
- D. I will massage my breasts before feeding to stimulate letdown.
Correct Answer: D
Rationale: Comfort measures for breast engorgement include massaging the breasts before feeding to stimulate letdown, alternating the breasts during feeding, taking a warm shower or applying warm compresses just before feeding, and wearing a supportive well-fitting bra at all times. None of the other options suggest correct measures.
The nurse is caring for a client with a history of breast cancer who is receiving chemotherapy. Which of the following laboratory values should the nurse monitor closely?
- A. White blood cell count.
- B. Blood glucose levels.
- C. Serum potassium.
- D. Hemoglobin A1c.
Correct Answer: A
Rationale: Chemotherapy can cause bone marrow suppression, requiring close monitoring of white blood cell counts for infection risk.