Nokea
The nurse is to perform a routine blood glucose check on a diabetic client before administering insulin. Which action is correct?
- A. Puncture the end of the thumb in the middle of the fleshy part.
- B. Puncture the end of the finger on the side.
- C. Draw blood from the antecubital vein in the arm.
- D. Puncture the finger and collect the blood in a vial.
Correct Answer: B
Rationale: Puncturing the finger's side avoids nerve-rich areas, ensuring accurate and less painful glucose testing.
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A 5-year-old child has been treated for sickle cell crisis. The parent asks the nurse if there is anything that can be done to prevent future crises. What should be included in the nurse's response?
- A. Sickle crisis is hard to predict and not usually preventable.
- B. Keeping the child from getting chilled may prevent a crisis.
- C. Fevers, vomiting, and diarrhea should be reported to the physician immediately.
- D. Giving the child aspirin on a daily basis lessens the frequency of crises.
Correct Answer: C
Rationale: Fevers, vomiting, and diarrhea can trigger sickle cell crisis by causing dehydration or infection, so prompt reporting allows early intervention to prevent crises.
A client before administration of captopril (Capoten).
The MOST appropriate nursing action before administration of captopril (Capoten) would be to check the client's
- A. apical pulse for 60 seconds.
- B. blood pressure.
- C. urine output.
- D. temperature.
Correct Answer: B
Rationale: Strategy: Think about each answer choice and how it relates to Capoten. (1) important, but not a priority (2) correct-is an antihypertensive that necessitates that a BP be assessed prior to administration (3) important, but not priority (4) unnecessary to assess prior to the administration of the medication
A 4 lb 10 oz baby boy delivered at 32 weeks gestation. The infant is admitted to the neonatal intensive care unit and placed in an incubator. He has mottling of the skin and acrocyanosis with irregular respirations of 60.
The nurse should recognize these findings as signs of
- A. hypoglycemia.
- B. cold stress.
- C. birth asphyxia.
- D. hypovolemia.
Correct Answer: B
Rationale: Strategy: Think about each answer choice. (1) blood sugar less than 25 mg/dL, would see cyanosis, apnea, tachypnea, irregular respirations, diaphoresis, jitteriness, weak cry, lethargy, convulsions, coma (2) correct-symptoms describe cold stress (3) would see meconium stained amniotic fluid (4) would see symptoms of shock
A client is admitted with acute abdominal pain. Which of the following findings would require immediate attention?
- A. BP 100/50, P 96, abdominal distention
- B. Temperature 99°, flatulence, nausea
- C. Urinary frequency and dysuria
- D. Temperature 99.2°, amber-colored urine
Correct Answer: A
Rationale: Hypotension (BP 100/50), tachycardia (P 96), and abdominal distention suggest a serious condition like internal bleeding or perforation, requiring immediate attention.
A client scheduled for a Nissen repair for a hiatal hernia is being instructed preoperatively to use the incentive spirometer. The nurse determines that the client has understood the teaching when the client states:
- A. These exercises will help to decrease my pain.
- B. I should use this device once a day.
- C. If I use this device, it will help in preventing pneumonia.
- D. I should do these breathing techniques while lying down flat in bed.
Correct Answer: C
Rationale: Incentive spirometry's purpose is to prevent or treat atelectasis, which can lead to pneumonia. Answer A is a false statement, so it is incorrect. Answer B is incorrect because the timing is not as often as it should be. Answer D is wrong because it is best done sitting upright.