Nokea
The nurse is teaching a client with type 1 diabetes about insulin administration. Which of the following statements by the client indicates a need for further teaching?
- A. I should rotate injection sites to prevent tissue damage.
- B. I should store my insulin in the refrigerator.
- C. I should check my blood sugar before giving insulin.
- D. I should inject insulin into my thigh if I’m going to exercise.
Correct Answer: D
Rationale: Injecting insulin into the thigh before exercise can increase absorption due to muscle activity, risking hypoglycemia. The abdomen is preferred for consistent absorption. Options A, B, and C are correct: rotation prevents lipodystrophy, refrigeration preserves insulin, and checking blood sugar ensures proper dosing.
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The nurse is supervising a student nurse administer a tube feeding to a client via a Levin tube. Which of the following actions, if performed by the student nurse, indicates a proper understanding of the correct procedure?
- A. The Levin tube remains unclamped for 30 minutes after the feeding.
- B. Sterile equipment is used to administer the feeding.
- C. The amount of the feeding is varied according to the patient's tolerance.
- D. The tube feeding is given at room temperature.
Correct Answer: D
Rationale: minimizes intestinal cramping
A client with pharyngitis.
The clinic nurse is obtaining a throat culture from a client with pharyngitis. It is MOST important for the nurse to do which of the following?
- A. Quickly rub a cotton swab over both tonsillar areas and the posterior pharynx.
- B. Obtain a sputum container for the client to use.
- C. Irrigate with warm saline, and then swab the pharynx.
- D. Hyperextend the client's head and neck for the procedure.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tonsillar and pharyngeal areas are quickly swabbed to avoid client discomfort (2) sputum specimen would not reflect throat bacteria (3) should not be done to obtain an adequate culture (4) client should hold the head upright, not hyperextended
The nurse is caring for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments?
- A. The client complains of epigastric pain.
- B. The client complains of shortness of breath.
- C. The client states she has increased rectal pressure.
- D. The client has gained of 33 pounds during her pregnancy.
Correct Answer: A
Rationale: is usually indicative of an impending convulsion
The nurse is assessing a client with suspected appendicitis. Which of the following findings would the nurse expect to observe?
- A. Pain relieved by pressure at McBurney's point.
- B. Rebound tenderness at McBurney's point.
- C. Pain in the left lower quadrant.
- D. Decreased bowel sounds in all quadrants.
Correct Answer: B
Rationale: rebound tenderness at McBurney's point is a classic sign of appendicitis
The nurse is preparing to suction a client with a new tracheostomy in the postanesthesia recovery room. Which of the following actions, if performed by the nurse, indicates a break in proper technique?
- A. The nurse sets the suction source at 120 mm Hg and obtains a #14 French suction catheter.
- B. The nurse inserts the suction catheter until resistance is met, and then applies intermittent suction as the catheter is withdrawn.
- C. The nurse suctions the client's mouth prior to suctioning the tracheostomy to ensure a patent airway.
- D. The nurse administers oxygen to the client using an Ambu bag attached to 100% oxygen prior to suctioning.
Correct Answer: C
Rationale: break in sterile procedure, suction mouth after trachea