Nokea
Which action is the best indication that the client needs more practice in combining two insulins in one syringe?
- A. The client rolls the vial of intermediate-acting insulin to mix it with its additive.
- B. The client still have a little or less the fast-acting and intermediate-acting insulin vials.
- C. The client instills the intermediate-acting insulin into the vial of rapid-acting insulin.
- D. The client inverts each vial before withdrawing the specified amount of insulin.
Correct Answer: C
Rationale: Instilling insulin into another vial contaminates the medication and is incorrect.
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What should be included in the nursing care plan for a client with diabetes insipidus?
- A. Blood pressure every hour
- B. Strict intake and output
- C. Urine for ketone bodies
- D. Glucose monitoring four times a day
Correct Answer: B
Rationale: Diabetes insipidus causes excessive urine output due to low antidiuretic hormone, requiring strict intake and output monitoring to assess fluid balance.
A client has a transsphenoidal hypophysectomy to remove a pituitary tumor. When the client returns to the nursing unit following surgery, the head of the bed is elevated 30 degrees. What is the primary purpose for placing the client in this position?
- A. To promote respiratory effort
- B. To reduce pressure on the sella turcica
- C. To prevent acidosis
- D. To promote oxygenation
Correct Answer: B
Rationale: Elevating the head 30 degrees reduces pressure on the sella turcica, minimizing the risk of cerebrospinal fluid leakage post-hypophysectomy.
The client is three (3) days postoperative unilateral adrenalectomy. Which discharge instructions should the nurse teach?
- A. Discuss the need for lifelong steroid replacement.
- B. Instruct the client on administration of vasopressin.
- C. Teach the client to care for the suprapubic Foley catheter.
- D. Tell the client to notify the HCP if the incision is inflamed.
Correct Answer: D
Rationale: Notifying the HCP for incision inflammation prevents infection post-adrenalectomy. Lifelong steroids are for bilateral procedures, vasopressin is for DI, and Foley catheters are not standard.
Two hours after taking a regular morning dose of regular insulin, the client presents to a clinic with diaphoresis, tremors, palpitations, and tachycardia. Which nursing action is most appropriate?
- A. Check pulse oximetry; if 94% or less, start oxygen at 2 L per nasal cannula.
- B. Give a baby aspirin and one nitroglycerin tablet; obtain an electrocardiogram.
- C. Check blood glucose level; provide carbohydrates if less than 70 mg/dL (3.8 mmol/L).
- D. Check heart rate; if the HR is above 120 beats per minute, give atenolol 25 mg orally.
Correct Answer: C
Rationale: Regular insulin peaks in 2 to 4 hours after administration. The client's symptoms suggest hypoglycemia, so a blood glucose level should be checked and carbohydrates given if low.
Which client problem has priority for the client diagnosed with acute pancreatitis?
- A. Risk for fluid volume deficit.
- B. Alteration in comfort.
- C. Imbalanced nutrition: less than body requirements.
- D. Knowledge deficit.
Correct Answer: A
Rationale: Fluid volume deficit is the priority in acute pancreatitis due to vomiting and third-spacing, risking hypovolemia. Pain, nutrition, and knowledge are secondary.