Nokea
A client administering his own insulin.
Which observation indicates to the nurse that the client needs further teaching before he can administer his own insulin?
- A. The client draws up his regular insulin first, then the NPH.
- B. The client gently rotates the insulin bottle before withdrawing the dose.
- C. The client rotates injection sites following the guide on his printed diagram.
- D. The client administers the insulin while it is still cold from the refrigerator.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) when mixing regular insulin with other types of insulin, the client should draw up the clear (regular) before the cloudy (NPH) (2) bottle of insulin should never be vigorously shaken, but rather gently mixed (3) imperative to rotate injection sites to avoid tissue irritation/infection and ensure proper absorption (4) correct-insulin should be administered at room temperature, temperature extremes should be avoided
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A client with a T6 injury 6 months ago develops facial flushing and a BP of 210/106. After elevating the head of the bed, which is the most appropriate nursing action?
- A. Notify the RN.
- B. Assess the client for a distended bladder.
- C. Apply oxygen at 3 L/min.
- D. Increase the IV fluids.
Correct Answer: B
Rationale: The symptoms suggest autonomic dysreflexia, often triggered by a distended bladder or bowel in clients with spinal cord injuries above T6. Assessing and addressing the trigger, such as a distended bladder, is the most appropriate action. Notifying the RN may be necessary but is not the immediate action, so answer A is incorrect. Oxygen and increased IV fluids do not address the cause, so answers C and D are incorrect.
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions should the nurse prioritize?
- A. Encourage log-rolling when repositioning
- B. Administer pain medication as needed
- C. Keep the head of the bed elevated 45 degrees
- D. Monitor the surgical drain for output
Correct Answer: A
Rationale: Log-rolling maintains spinal alignment, preventing complications post-laminectomy. Options B, C, and D are secondary: pain management is routine, 45-degree elevation is excessive, and drain monitoring is less urgent.
A 63-year-old woman is taking digitalis, baby aspirin, potassium (K-Dur), and furosemide (Lasix) daily. She complains of multiple symptoms, which include muscle cramps and facial tics. Physical exam reveals positive Chvostek's and Trousseau's signs, hypotension, and confusion. The nurse suspects she has hypomagnesemia. What else should the nurse expect?
- A. Laboratory tests to reveal high serum calcium and potassium levels
- B. Laboratory tests to reveal low serum calcium and potassium levels
- C. Altered acid-base balance, which requires administration of NaHCO3 intravenously in addition to treatment for hypomagnesemia
- D. An order for an ECG to monitor brain function
Correct Answer: B
Rationale: Hypomagnesemia often accompanies low calcium and potassium, as seen with furosemide use, explaining symptoms like cramps and tetany.
The primary purpose for using a CPM machine for the client with a total knee repair is to help:
- A. Prevent contractures.
- B. Promote flexion of the artificial joint.
- C. Decrease the pain associated with early ambulation.
- D. Alleviate lactic acid production in the leg muscles.
Correct Answer: A
Rationale: A CPM machine prevents contractures by maintaining joint mobility post-knee repair. It aids flexion but primarily prevents stiffness. Pain and lactic acid are secondary concerns.
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client's plan of care?
- A. Weighing the client after she eats
- B. Having a staff member remain with her for 1 hour after she eats
- C. Placing high-protein foods in the center of the client's plate
- D. Providing the client with child-sized utensils
Correct Answer: B
Rationale: Having a staff member stay with the client for 1 hour after eating prevents purging, a common behavior in anorexia nervosa.