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Which of the following nursing interventions should be taken for a client who complains of nausea and vomits one hour after taking his glyburide (DiaBeta)?
- A. Administer glyburide again
- B. Administer subcutaneous insulin and monitor blood glucose
- C. Monitor blood glucose closely, and look for signs of hypoglycemia
- D. Monitor blood glucose and assess for signs of hyperglycemia
Correct Answer: C
Rationale: After a client complains of nausea and vomits one hour after taking glyburide, the priority nursing intervention should be to monitor blood glucose closely and look for signs of hypoglycemia. Vomiting could indicate that the glyburide was not properly absorbed, potentially leading to hypoglycemia. Administering glyburide again (Choice A) could worsen hypoglycemia. Administering subcutaneous insulin (Choice B) is not appropriate without assessing the blood glucose first. Monitoring for signs of hyperglycemia (Choice D) is not the immediate concern in this situation.
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Select a myth or falsehood relating to pain, pain management, and addiction.
- A. Addiction can be accurately predicted.
- B. Withdrawal, drug tolerance, and physical dependence do not indicate addiction.
- C. Pain medications should be avoided in patients with a substance abuse history.
- D. Addiction is signaled by deception and stockpiling by the client.
Correct Answer: A
Rationale: The correct answer is A because addiction cannot be accurately predicted. Choices B and C are incorrect. Withdrawal, drug tolerance, and physical dependence are not definitive signs of addiction, and pain medications can be used with patients who have a substance abuse history under careful monitoring. Choice D is incorrect because addiction is not solely signaled by deception and stockpiling; it is a complex condition with various behavioral, physical, and psychological aspects.
How do the public view nurses today?
- A. Nurses are assistants to physicians.
- B. Nurses view the person within the family and community.
- C. Nurses are different from other health-care providers.
- D. Nurses are closely involved in shaping the health care of the future.
Correct Answer: A
Rationale: The correct answer is A: 'Nurses are assistants to physicians.' The public image of nurses, as portrayed by the media, often positions them as assistants to physicians. This perception stems from historical depictions and the traditional hierarchy within healthcare settings. Choice B is incorrect because it reflects how nurses perceive their patients, not how the public views nurses. Choice C is incorrect as nurses are part of the broader healthcare team but are not seen as fundamentally different from other healthcare providers by the public. Choice D is incorrect as while nurses play a crucial role in shaping healthcare, the public perception often focuses more on their supportive role in the healthcare system.
Low birth weight is defined as a newborn's weight of:
- A. 2500 grams or less at birth, regardless of gestational age.
- B. 1500 grams or less at birth, regardless of gestational age.
- C. 2500 grams or less at birth, according to gestational age.
- D. 1500 grams or less at birth, according to gestational age.
Correct Answer: A
Rationale: Low birth weight is defined as 2500 grams or less at birth, regardless of gestational age. This means that any newborn weighing 2500 grams or less is considered to have a low birth weight, irrespective of how many weeks they were in the womb. Choices B, C, and D are incorrect because they specify a weight of 1500 grams or less, which is not the standard definition of low birth weight. The correct definition is 2500 grams or less, not influenced by gestational age.
Which of the following assessment tools is used to determine the patient's level of consciousness?
- A. The Snellen Scale
- B. The Norton Scale
- C. The Morse Scale
- D. The Glasgow Scale
Correct Answer: D
Rationale: The correct answer is D, The Glasgow Scale. The Glasgow Coma Scale is specifically designed to assess a patient's level of consciousness by evaluating eye opening, verbal response, and motor response. Choices A, B, and C are incorrect because the Snellen Scale is used for vision testing, the Norton Scale is used for assessing the risk of pressure sores, and the Morse Scale is used for evaluating a patient's risk of falling, not for determining the level of consciousness.
A nurse manager is reviewing isolation guidelines with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates understanding of isolation guidelines?
- A. I will have a client who is on airborne precautions wear a mask when out of their room.
- B. I will wear an N95 respirator mask for a client who is on droplet precautions.
- C. I will place a client who has compromised immunity in a negative-pressure airflow room.
- D. I will instruct visitors to wear a mask when visiting a client who is on contact precautions.
Correct Answer: A
Rationale: The correct answer is A. Having a client on airborne precautions wear a mask when out of their room is appropriate to prevent the spread of infection. Choice B is incorrect because the healthcare provider, not the client, wears an N95 respirator mask for a client on droplet precautions. Choice C is incorrect because negative-pressure airflow rooms are used for clients with airborne infections, not compromised immunity. Choice D is incorrect because visitors, not clients, should wear a mask when visiting a client on contact precautions.