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 answer is A because maintaining consistency in the order of drawing different types of insulin into the syringe helps prevent medication errors. When mixing insulins, drawing them in the same sequence ensures the correct dose and prevents contamination.
Explanation:
A: Following the same order ensures accurate dosing and minimizes the risk of mixing up insulins.
B: Shaking the vial can cause air bubbles which can affect the accuracy of the dose.
C: Storing insulin in the freezer can damage the medication and alter its effectiveness.
D: Cloudiness in intermediate-acting insulin is normal and does not indicate it should be discarded.
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How does nosocomial pneumonia occur?
- A. In a healthcare setting
- B. Within 48hrs of admission to a healthcare
- C. In the immunocompromised host facility
- D. In a community setting
Correct Answer: A
Rationale: The correct answer is A because nosocomial pneumonia occurs in a healthcare setting, such as hospitals or long-term care facilities, where patients are at increased risk due to exposure to pathogens and weakened immune systems. Choice B is incorrect as the timeframe of onset is not limited to within 48 hours of admission. Choice C is incorrect as nosocomial pneumonia can occur in both immunocompromised and immunocompetent hosts. Choice D is incorrect as it refers to pneumonia acquired outside of a healthcare setting.
The nurse is intervening for a family member with role strain. Which direct care nursing intervention is most appropriate?
- A. Assisting with activities of daily living
- B. Counseling about respite care options
- C. Teaching range-of-motion exercises
- D. Consulting with a social worker
Correct Answer: B
Rationale: The correct answer is B: Counseling about respite care options. This intervention is most appropriate as it addresses the issue of role strain by providing the family member with support and options for temporary relief from caregiving responsibilities. Respite care allows the family member to take a break and recharge, reducing stress and preventing burnout.
A: Assisting with activities of daily living is important but may not directly address the underlying issue of role strain.
C: Teaching range-of-motion exercises is beneficial for physical well-being but does not directly address the emotional and psychological impact of role strain.
D: Consulting with a social worker may be helpful for additional support but may not provide immediate relief or practical solutions for the family member's role strain.
Mang Simon, a hypertensive male client was prescribed with an exercise program. Which intervention would help Mang Simon in maintaining this program?
- A. writing down the exercise program
- B. thoroughly explaining the program to his wife, Aling Nena
- C. Motivating him positively that he can do it
- D. Doing it according to his needs and abilities
Correct Answer: D
Rationale: The correct answer is D: Doing it according to his needs and abilities. This option is the most appropriate intervention for Mang Simon to maintain his exercise program. By tailoring the program to his needs and abilities, Mang Simon is more likely to adhere to it and prevent any potential injuries or health risks associated with overexertion. This approach ensures that the exercise routine is realistic and manageable for him, increasing his chances of long-term success.
A: Writing down the exercise program may be helpful for organization but does not address the individualization needed for Mang Simon's specific situation.
B: Thoroughly explaining the program to his wife, Aling Nena, may provide support but does not directly impact Mang Simon's ability to maintain the program.
C: Positive motivation is important, but it alone may not be sufficient to address the practical aspects of adapting the exercise program to Mang Simon's needs and abilities.
The nurse is observing a client receiving antiplatelet therapy for adverse reactions. Antiplatelet drugs most commonly produce which hypersensitivity reaction?
- A. Difficulty hearing
- B. Confusion
- C. Bronchospasm
- D. Agranulocytosis
Correct Answer: C
Rationale: The correct answer is C: Bronchospasm. Antiplatelet drugs commonly cause hypersensitivity reactions like bronchospasm due to their effects on platelet function. They can trigger an allergic response leading to bronchoconstriction. Difficulty hearing (A) is not a common hypersensitivity reaction to antiplatelet therapy. Confusion (B) is more commonly associated with central nervous system effects rather than hypersensitivity reactions. Agranulocytosis (D) is a severe drop in white blood cells and is not typically a hypersensitivity reaction to antiplatelet drugs.
Mr. Garcia, a 41-year old chronic alcohol drinker is admitted to the hospital after vomiting bright red blood. He was diagnosed to have a bleeding gastric ulcer and suddenly develops sudden sharp pain in the midepigastric region with a rigid boardlike abdomen. This likely indicates:
- A. development of intestinal
- B. inflammation of the esophagus
- C. perforation of the ulcer
- D. development of additional ulcers
Correct Answer: C
Rationale: The sudden sharp pain in the midepigastric region with a rigid boardlike abdomen in a patient with a bleeding gastric ulcer indicates a perforation of the ulcer. Perforation leads to leakage of gastric contents into the peritoneal cavity, causing peritonitis. This presentation requires immediate surgical intervention. Option A is incorrect as intestinal development does not correlate with the symptoms described. Option B is incorrect because inflammation of the esophagus would not lead to a rigid boardlike abdomen. Option D is incorrect as the sudden onset of symptoms is more indicative of a complication like perforation rather than the development of additional ulcers.