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1. A nurse administers subcutaneous lispro insulin 0715
at 0700 to a client who has diabetes. At which of
the following times should the nurse observe for
hypoglycemia caused by the onset of the medica-
tion?
2. What is required by medical asepsis that is not good hand washing technique
required by surgical asepsis?
3. A nurse is preparing to administer dexametha- 3.8
sone 1.5 mg/kg/day PO to divide equally every
6 hours to a preschool-age child who weighs 22
lb. Available is dexamethasone oral solution 1
mg/mL. How many mL should the nurse admin-
ister per dose? (Round the answer to the nearest
tenth.)
4. A postoperative client who has no previous med- Start oxygen at 2 liters per nasal
ical conditions is difficult to arouse when trans- cannula.
ferred to the surgical unit from the post-anesthe-
sia care unit. A nurse monitors the pulse oximeter
and gets a reading of 85%. The nurse arouses
the client and has him cough and perform deep
breathing; the pulse oximeter is now reading 83%
what should be the nurse's next action?
5. A nurse in the emergency department knows that 95
tissue damage has probably occurred in a person
with hypothermia when a rectal temperature of
_____ is assessed. (do not use degree sign,)
6. At 0330, a nurse is caring for a client who is post- 300
operative. The client's IV fluids are infusing at 120
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mL/hr. How many mL of IV fluid should infuse by
0600? (Round the answer to the nearest whole
number. Use a leading zero if it applies. Do not
use a trailing zero.)
7. A nurse is reinforcing teaching with a client who Within the expected reference
has a family history of hypertension. The nurse range
should inform the client that his blood pressure
reading of 112/64 mm Hg places him in which of
the following categories?
8. A nurse is reinforcing teaching with a client who -Blurry vision
has type 2 diabetes mellitus. The nurse deter- -tachycardia
mines that teaching has been effective when the -sweating
client identifies which of the following manifesta-
tions of hypoglycemia? (Select all that apply.)
9. A nurse is reinforcing teaching with a client who "It is best for you to drink an occa-
has diabetes mellitus and self-administers in- sional glass of wine with a meal".
sulin. The client reports drinking an occasional
glass of wine. Which of the following is an appro-
priate response by the nurse?
10. A nurse is caring for a client who has type 1 di- Check the client's blood glucose
abetes mellitus. The nurse misread the client's level.
morning fasting blood glucose level as 210 mg/dL
instead of 120 mg/dL and administered the in-
sulin dose appropriate for a reading over 200
mg/dL. Which of the following actions should the
nurse identify as the priority?
11. A nurse is assisting with the plan of care for a Keep the clients affected leg ele-
client who has a new deep-vein thrombosis (DVT) vated
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in his leg. Which of the following interventions
should the nurse include in the plan?
12. A nurse is collecting data from a client who unilateral leg edema
is postoperative following abdominal surgery.
Which of the following findings should cause the
nurse to suspect deep-vein thrombosis (DVT)?
13. A nurse is collecting data from a client who has Heart failure
hypertension and a prescription for propranolol.
A history of which of the following conditions
should be reported to the provider?
14. A nurse is caring for an older adult client who Help the client write down ques-
has colon cancer. The client asks the nurse several tions to ask his provider.
questions about his treatment plan. Which of the
following actions should the nurse take?
15. A nurse is collecting data from client who has re- Manifestations of infection.
ceived chemotherapy to treat lung cancer. Which
of the following adverse effects should the nurse
report to the provider?
16. A nurse is assisting with the plan of care for a Auscultate lung fields
client who has pneumonia and requires chest
percussion, vibration, and postural drainage.
Which of the following actions should the nurse
plan to complete first?
17. A nurse is collecting data from a client who has Decreased level of consciousness
pneumonia and is experiencing acute respiratory
acidosis. Which of the following manifestations
should the nurse expect to find?