Nokea
The nurse knows that which psychosocial stage should be a priority to consider while planning care for a 20-year-old client?
- A. Identity versus identity diffusion.
- B. Intimacy versus isolation.
- C. Integrity versus despair and disgust.
- D. Industry versus inferiority.
Correct Answer: B
Rationale: is the stage for 19- to 35-year-olds
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The nurse is to administer the daily dose of digoxin to an adult client. What is it essential for the nurse to do before administering the medication?
- A. Check the client's temperature
- B. Check the client's blood pressure
- C. Check the client's respirations
- D. Check the client's apical pulse
Correct Answer: D
Rationale: Digoxin slows heart rate; checking the apical pulse ensures it's above 60 bpm to avoid bradycardia. Temperature, blood pressure, and respirations are less critical.
The nurse is caring for a client with a history of sickle cell disease.
- A. Which intervention is most effective during a sickle cell crisis?
- B. Administer oxygen therapy.
- C. Encourage ambulation.
- D. Apply cold compresses to painful areas.
- E. Restrict fluid intake.
Correct Answer: A
Rationale: Oxygen therapy improves oxygenation, reducing sickling and tissue hypoxia during a sickle cell crisis. Ambulation is limited, cold compresses worsen vasoconstriction, and fluids are encouraged to prevent dehydration.
A client has recently been diagnosed with Type 1 diabetes mellitus. The nurse is instructing the client about self-administering insulin. What should be included in the teaching? Select all that apply.
- A. Pinch the muscle and inject the needle at a 45-degree angle.
- B. Shake the vial of insulin before drawing it up.
- C. When using the abdominal site, inject at least 1 inch from the umbilicus.
- D. When mixing insulins, draw up the regular insulin before the NPH.
- E. Do a finger stick glucose test before administering insulin.
- F. Use one site per day for insulin injections.
Correct Answer: C,D,E
Rationale: Injecting 1 inch from the umbilicus ensures absorption, drawing regular insulin before NPH prevents contamination, and checking glucose confirms dosing need. Pinch skin (not muscle), don't shake insulin, and rotate sites.
An elderly client with a fractured hip is placed in Buck's traction. The primary purpose for Buck's traction for this client is:
- A. To decrease muscle spasms
- B. To prevent the need for surgery
- C. To alleviate the pain associated with the fracture
- D. To prevent bleeding associated with hip fractures
Correct Answer: A
Rationale: Buck's traction immobilizes the hip to reduce muscle spasms, which can worsen pain and misalignment. It does not prevent surgery or bleeding and is not primarily for pain relief.
The nurse is supervising care given to clients on a medical/surgical unit.
The nurse should intervene if which of the following is observed?
- A. A nurse and client wear masks during a dressing change for the central catheter used for total parenteral nutrition.
- B. A nurse injects insulin through a single-lumen percutaneous central catheter for client receiving total parenteral nutrition.
- C. A nurse applies lip balm to his/her lips immediately after performing a blood draw to obtain a specimen.
- D. A nurse wears a disposable particulate respirator when administering rifampin to a client with tuberculosis.
Correct Answer: C
Rationale: Strategy: 'Nurse should intervene' indicates that you are looking for an incorrect action. (1) appropriate procedure, prevents airborne contamination (2) insulin is the only medication that can be given, compatible with TPN (3) correct-applying lip balm or handling contact lenses is prohibited in work areas where exposure to bloodborne pathogens may occur (4) use airborne precautions for TB, private room with negative air pressure, minimum of six exchanges per hour