Nokea
Which instruction about insulin administration should the nurse give to a client?
- A. "Always follow the same order when drawing the different insulin into the syringe."
- B. "Shake the vial before withdrawing the insulin."
- C. "Store unopened vials of insulin in the freezer at temperatures well below freezing."
- D. "Discard the intermediate-acting insulin if it disappears cloudy."
Correct Answer: A
Rationale: The correct instruction the nurse should give to the client is to "Always follow the same order when drawing the different insulin into the syringe." This is important because mixing different insulins in the same syringe can alter their action profiles and lead to inaccurate dosing. It is crucial to follow a consistent order to prevent mixing the insulins inadvertently. It is advisable to consult a healthcare provider or pharmacist for specific instructions on insulin administration to ensure safety and effectiveness.
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When communicating with other professionals, what is important for the nurse to do?
- A. Ask others what they want to know.
- B. Share everything known about the family.
- C. Restrict communication to clinically relevant information.
- D. Recognize that confidentiality is not possible.
Correct Answer: C
Rationale: When communicating with other professionals, it is important for the nurse to restrict communication to clinically relevant information. This ensures that only necessary and pertinent information is shared, maintaining patient confidentiality and preventing the unnecessary dissemination of sensitive details. By focusing on clinically relevant information, healthcare professionals can collaborate effectively and make well-informed decisions about patient care without compromising confidentiality or violating ethical guidelines.
A nurse is preparing to complete an admission assessment on a 2-year-old child. The child is sitting on the parent's lap. Which technique should the nurse implement to complete the physical exam?
- A. Ask the parent to place the child in the hospital crib.
- B. Take the child and parent to the exam room.
- C. Perform the exam while the child is on the parent's lap.
- D. Ask the child to stand by the parent while completing the exam.
Correct Answer: C
Rationale: The most appropriate technique in this scenario would be to perform the exam while the child is on the parent's lap. This approach helps build trust and comfort for the child, as they are in a familiar and secure environment. It can also help the nurse assess the child's behavior and interactions with the parent during the exam, providing valuable information about the child's developmental stage and emotional well-being. Additionally, conducting the exam in this way can help reduce anxiety and fear that the child may experience in an unfamiliar setting like the hospital crib or exam room.
Which of the following is the medication of choice for anaphylaxis that the nurse should anticipate would be ordered?
- A. Epinephrine
- B. Digoxin (Lanoxin)
- C. Theophylline (Theo-Dur)
- D. Furosemide (Lasix)
Correct Answer: A
Rationale: Epinephrine is the medication of choice for anaphylaxis. Anaphylaxis is a severe and potentially life-threatening allergic reaction that can lead to a rapid drop in blood pressure, airway constriction, and other serious symptoms. Epinephrine acts quickly to reverse these symptoms by constricting blood vessels, relaxing the muscles in the airways, and increasing heart rate. It is administered via an auto-injector device, such as an EpiPen, in cases of severe allergic reactions. Other medications, such as antihistamines and corticosteroids, may be given as adjunct therapy, but epinephrine is the first-line treatment for anaphylaxis. Thus, the nurse should anticipate that epinephrine would be ordered for a patient experiencing anaphylaxis.
In assessing a post mastectomy client, the nurse determines that the client is in denial. The nurse can best respond by:
- A. Accepting the denial.
- B. Supporting the denial.
- C. Confronting the denial.
- D. Interpreting the denial.
Correct Answer: C
Rationale: Confronting the denial is the best response in this situation. Denial is a common defense mechanism that individuals may use when faced with overwhelming emotions or situations, such as in the case of a post-mastectomy client. By confronting the denial in a supportive and empathetic manner, the nurse can help the client acknowledge and accept their feelings, which is an important step in the healing and coping process. Ignoring or supporting the denial may hinder the client's ability to address their emotions and work through them effectively. Confronting the denial allows for open communication and helps the client move towards acceptance and adjustment.
An adolescent girl calls the nurse at the clinic because she had unprotected sex the night before and does not want to be pregnant. What should the nurse explain to the girl?
- A. It is too late to prevent an unwanted pregnancy
- B. An abortion may be the best option if she is pregnant
- C. Norplant can be administered to prevent pregnancy for up to 5 years
- D. Postcoital contraception is available to prevent implantation
Correct Answer: D
Rationale: In this scenario, the most appropriate option for the nurse to explain to the adolescent girl is postcoital contraception, also known as emergency contraception or the morning-after pill. Postcoital contraception is a method used to prevent pregnancy after unprotected sex or contraceptive failure. It works by preventing or delaying ovulation, inhibiting fertilization, or preventing implantation of a fertilized egg in the uterus.