Nokea
The nurse is teaching a client with a new diagnosis of type 2 diabetes about insulin detemir (Levemir). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should rotate injection sites.
- C. I should refrigerate unopened vials.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin detemir when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, rotation prevents lipodystrophy, and refrigeration preserves insulin.
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A client is scheduled for a cardiac catheterization at 8 AM. The client's laboratory work was completed five days ago. The results were: K⺠3.0 mEq/L, Na⺠148 mEq/L, glucose 178 mg/dL. He complains of muscle weakness and cramps.
Which of the following nursing actions is BEST?
- A. Administer the 7 AM dose of spironolactone (Aldactone).
- B. Encourage eating bananas for breakfast.
- C. Obtain stat K⺠level.
- D. Call for twelve-lead EKG.
Correct Answer: C
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) Aldactone is potassium-sparing diuretic and is an oral medication, patient is NPO for procedure (2) is not feasible prior to the cardiac cath because the client is NPO (3) correct-signs and symptoms are indicative of hypokalemia; stat serum K⺠level is needed to confirm the K⺠level prior to going for cardiac catheterization (4) is unnecessary at this time
A 19-year-old woman after delivery of a 7 lb 10 oz baby boy. The patient has decided to bottle-feed her infant.
The nurse should encourage the patient to
- A. use the manual breast pump to relieve breast engorgement.
- B. apply warm packs to the breast to relieve discomfort.
- C. massage the breasts to reduce engorgement and discomfort.
- D. wear a well supportive bra and take Tylenol for discomfort.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will encourage milk secretion (2) will enhance flow of milk (3) may be taut due to engorgement, massage would be painful and unnecessary, will encourage milk flow (4) correct-will help minimize discomfort during period of engorgement
The registered nurse has just admitted a client with severe depression. What domain should be the priority focus as the nurse identifies the nursing diagnoses?
- A. Nutrition
- B. Elimination
- C. Activity
- D. Safety
Correct Answer: D
Rationale: Safety. A depressed client is at acute risk for self-destructive behavior, making safety the priority.
The physician's orders include warm compresses to the left leg three times a day for treatment of an open wound. Which action is appropriate when carrying out these orders?
- A. Use medical aseptic technique.
- B. Leave the wet compress open to the air.
- C. Place both a dry covering and waterproof material over the compress.
- D. Remove the compress after five minutes.
Correct Answer: C
Rationale: A dry covering and waterproof material over the compress maintain warmth and prevent contamination while keeping the surrounding area dry. Aseptic technique is needed for open wounds, open-air compresses lose heat, and five minutes is too short.
An adult client became incontinent while hospitalized. The client now drinks very little. The nurse understands that this is:
- A. a coping strategy.
- B. a defense mechanism.
- C. a way to not bother the nurse.
- D. regression.
Correct Answer: A
Rationale: Reduced fluid intake is a coping strategy to avoid incontinence, though it risks dehydration, reflecting an attempt to manage embarrassment.