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Which intervention is most important for the nurse to implement for a client who is receiving insulin lispro?
- A. Assess for hypoglycemia between meals.
- B. Check blood glucose levels every six hours.
- C. Provide meals at the same time this insulin is given.
- D. Keep an oral liquid or glucose source available.
Correct Answer: C
Rationale: Insulin lispro, a rapid-acting insulin, peaks quickly and should be given with meals (C) to match food intake and prevent hypoglycemia. Assessing for hypoglycemia (A) and keeping glucose sources (D) are important but secondary. Six-hour glucose checks (B) are too infrequent.
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A client reports confusion and blurred vision after receiving a dose of glipizide. What should the nurse do?
- A. Administer glucagon intramuscularly.
- B. Measure the client’s vital signs.
- C. Obtain a fingerstick blood glucose.
- D. Perform a neurological exam.
Correct Answer: C
Rationale: Glipizide, a sulfonylurea, can cause hypoglycemia, presenting as confusion and blurred vision. Checking blood glucose (C) confirms the cause. Glucagon (A) treats severe hypoglycemia, not confirmed yet. Vital signs (B) and neurological exams (D) are secondary.
Before administering the evening dose of carbamazepine, the nurse notes that the patient’s morning carbamazepine level was 84 mcg/mL. What action should the nurse take?
- A. Notify the healthcare provider of the carbamazepine level.
- B. Administer the carbamazepine as prescribed.
- C. Withhold this dose of the carbamazepine.
- D. Assess the patient for side effects of carbamazepine.
Correct Answer: A
Rationale: Carbamazepine’s therapeutic range is 4-12 mcg/mL; 84 mcg/mL (A) indicates toxicity risk, requiring provider notification. Administering (B) or withholding (C) without consultation is unsafe. Assessing side effects (D) is secondary to reporting.
A client with Parkinson’s disease who is taking carbidopa/levodopa reports that the urine appears to be darker in color. What action should the nurse take?
- A. Encourage an increase in oral intake.
- B. Explain that the color change is normal.
- C. Obtain a specimen for a urine culture.
- D. Measure the client’s urinary output.
Correct Answer: B
Rationale: Carbidopa/levodopa can darken urine (B), a benign side effect. Increased fluids (A) or urine culture (C) are unnecessary unless other symptoms arise. Measuring output (D) doesn’t address the color change.
A client with psychosis is receiving an antipsychotic medication and is continually rubbing the back of the neck. What is the best nursing intervention?
- A. Obtain an extra pillow for the client to use at night.
- B. Give a PRN prescription for benztropine.
- C. Provide the client a heating pad to place on the neck.
- D. Obtain a prescription for physical therapy services.
Correct Answer: B
Rationale: Neck rubbing suggests extrapyramidal symptoms (e.g., dystonia) from antipsychotics. Benztropine (B), an anticholinergic, relieves these symptoms. Pillows (A), heating pads (C), and physical therapy (D) don’t address the cause.
A female patient with multiple sclerosis reports less fatigue and improved memory since she started using the herbal supplement, ginkgo biloba. What is the most important information for the nurse to include in the teaching plan for this patient?
- A. Nausea and diarrhea can occur when using this supplement.
- B. Ginkgo biloba use should be limited and not taken during pregnancy.
- C. Aspirin and non-steroidal anti-inflammatory drugs interact with ginkgo.
- D. Anxiety and headaches increase with the use of ginkgo biloba.
Correct Answer: C
Rationale: This question is identical to Question 39. Ginkgo biloba’s interaction with aspirin/NSAIDs (C) increases bleeding risk, a critical teaching point. Other side effects (A, D) and pregnancy limits (B) are less urgent. Note: Duplicate question; consider removing.