Nokea
. Which of the following instructions should be included in the teaching plan for a client requiring insulin?
- A. Administer insulin after the first meal of the day.
- B. Administer insulin at a 45-degree angle into the deltoid muscle.
- C. Shake the vial of insulin vigorously before withdrawing the medication.
- D. Draw up clear insulin first when mixing two type of insulin in one syringe.
Correct Answer: D
Rationale: The correct answer is D: Draw up clear insulin first when mixing two types of insulin in one syringe. This is important because mixing insulin requires drawing up the clear (short-acting) insulin first to prevent contamination. This ensures accurate dosing and prevents clouding of the insulin. Drawing up cloudy insulin first can lead to inaccurate dosing and potential mixing errors. Administering insulin after the first meal (choice A) is not the focus of this question. Administering insulin at a 45-degree angle into the deltoid muscle (choice B) is not recommended for insulin injections. Vigorously shaking the vial of insulin before withdrawal (choice C) can cause bubbles and affect the accuracy of the dose.
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A registered nurse administers pain medication to a patient suffering from fractured ribs. Which type of nursing intervention is this nurse implementing?
- A. Collaborative
- B. Independent
- C. Interdependent
- D. Dependent
Correct Answer: D
Rationale: The correct answer is D: Dependent. In this scenario, the nurse is administering pain medication based on a healthcare provider's prescription, which demonstrates a dependent nursing intervention. The nurse is reliant on the provider's order to carry out this action. Collaborative interventions involve working with other healthcare professionals, independent interventions are actions that nurses can initiate without supervision, and interdependent interventions involve mutual goal-setting and decision-making among healthcare team members.
Mrs. Silang, a 52-year old female, is experiencing advanced hepatic cirrhosis now complicated by hepatic encephalopathy. She is confused, restless, and demonstrating asterixis. The nurse has formulated the nursing diagnosis: Altered thought processes related to which of the following?
- A. massive ascites formation
- B. fluid volume excess
- C. increased serum ammonia levels
- D. altered clotting mechanism
Correct Answer: C
Rationale: The correct answer is C: increased serum ammonia levels. In hepatic encephalopathy, the liver is unable to metabolize ammonia, leading to its accumulation in the bloodstream, causing altered thought processes. This results in confusion and asterixis. Massive ascites formation (choice A) is related to fluid accumulation in the peritoneal cavity, not directly linked to altered thought processes. Fluid volume excess (choice B) is a general fluid imbalance issue, not specific to hepatic encephalopathy. Altered clotting mechanism (choice D) is more associated with hepatic dysfunction leading to impaired clotting factors, not directly linked to altered thought processes.
Which of the following is a nurse patient care role in the preoperative phase?
- A. Obtaining preoperative orders
- B. Offering emotional support
- C. Explaining the surgical procedure
- D. Providing informed consent
Correct Answer: B
Rationale: The correct answer is B: Offering emotional support. In the preoperative phase, a nurse's role includes comforting and reassuring the patient to reduce anxiety and promote emotional well-being. This is crucial for the patient's overall experience and can positively impact their recovery. Obtaining preoperative orders (A) is typically the responsibility of the physician. Explaining the surgical procedure (C) is usually done by the surgeon. Providing informed consent (D) involves ensuring the patient understands the risks and benefits of the procedure, which is typically the responsibility of the healthcare provider performing the procedure.
The nurse should expect a client with hypothyroidism to report which health concerns?
- A. Increased appetite and weight loss
- B. Nervousness and tremors
- C. Puffiness of the face and hands
- D. Thyroid gland swelling
Correct Answer: C
Rationale: The correct answer is C. In hypothyroidism, the thyroid gland is underactive, leading to symptoms like puffiness of the face and hands due to fluid retention. This occurs as a result of decreased metabolism. Options A and B are symptoms of hyperthyroidism, where the thyroid gland is overactive. Option D is a symptom of goiter, which is thyroid gland swelling, not specific to hypothyroidism. Therefore, the correct answer is C based on the characteristic symptoms of hypothyroidism.
What equipment should the nurse prepare for the primary care provider when a woman says she is concerned about possible Chlamydia infection?
- A. Chlamydia slide
- B. Chlamydia collection kit
- C. Chlamydia swab
- D. Chlamydia wet mount
Correct Answer: B
Rationale: The correct answer is B: Chlamydia collection kit. The primary care provider will need the collection kit to gather a sample for testing. A Chlamydia slide (A) is not necessary as the provider needs to collect a sample first. A Chlamydia swab (C) is used to collect the sample, not to provide to the provider. A Chlamydia wet mount (D) is not appropriate for Chlamydia testing, as it is typically used for other types of infections.