Nokea
When the client practices self-administration of the insulin, which action is correct?
- A. Piercing the skin at a 30-degree angle
- B. Using a syringe calibrated in minims
- C. Using a 29-gauge needle on the syringe
- D. Rotating abdominal sites for each injection
Correct Answer: D
Rationale: Rotating abdominal sites prevents lipodystrophy and ensures consistent insulin absorption.
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Which signs/symptoms should the nurse expect to assess in the 31-year-old client who has a sustained release of growth hormone (GH)?
- A. An enlarged forehead, maxilla, and face.
- B. A six (6)-inch increase in height of the client.
- C. The client complaining of a severe headache.
- D. A systolic blood pressure of 200 to 300 mm Hg.
Correct Answer: A
Rationale: Excess GH (acromegaly) causes facial and bone enlargement (e.g., forehead, maxilla). Height increase occurs pre-puberty, headaches are nonspecific, and extreme hypertension is unrelated.
The client with DM is to receive insulin IV at 1.5 units per hour. The insulin bag contains 10 units of insulin in 100 mL of NS. The nurse should set the infusion pump to deliver how many milliliters per hour?
- A. 1.0 mL/hr
- B. 1.5 mL/hr
- C. 2.0 mL/hr
- D. 2.5 mL/hr
Correct Answer: B
Rationale: 10 units : 100 mL :: 1.5 units : X mL; 10X = 150; X = 1.5 mL/hr.
The client diagnosed with Addison's disease is admitted to the emergency department after a day at the lake. The client is lethargic, forgetful, and weak. Which intervention should the nurse implement?
- A. Start an IV with an 18-gauge needle and infuse NS rapidly.
- B. Have the client wait in the waiting room until a bed is available.
- C. Obtain a permit for the client to receive a blood transfusion.
- D. Collect urinalysis and blood samples for a CBC and calcium level.
Correct Answer: A
Rationale: Lethargy, confusion, and weakness suggest Addisonian crisis; rapid NS infusion corrects hypotension and dehydration. Waiting, transfusions, and labs are inappropriate first steps.
To prepare for potential postoperative complications related to the thyroidectomy, which item is necessary to keep at the client's bedside?
- A. Dressing change kit
- B. Tracheostomy tray
- C. Ampule of epinephrine
- D. Mechanical ventilator
Correct Answer: B
Rationale: A tracheostomy tray is essential in case of airway obstruction due to swelling or hematoma post-thyroidectomy.
Which problem is most likely to develop if hyperthyroidism remains untreated?
- A. Pulmonary embolism
- B. Respiratory acidosis
- C. Cerebro vascular accident
- D. Heart failure
Correct Answer: D
Rationale: Untreated hyperthyroidism causes severe tachycardia, which can lead to heart failure due to increased cardiac workload.