A nurse is preparing to mix short-acting and intermediate-acting insulin in one syringe to
administer to a client who has type 1 diabetes mellitus. Identify the sequence the nurse
should follow.
(answer)- 1: Draw up the volume of insulin from the intermediate-acting insulin vial.
2: Inject the volume of air equal to the amount of insulin to withdraw from the
intermediate-acting insulin vial.
3: Inject the volume of air equal to the insulin dose form the short-acting insulin vial
4: Withdraw the prescribed amount of insulin form the short-acting insulin vial.
5: Withdraw the prescribed amount of insulin form the intermediate-acting insulin vial.
A nurse is assessing a client who wears partial dentures and reports mouth pain. Which
of the following actions should the nurse take?
(answer)- Advise the client to rinse their mouth and dentures after each meal.
A nurse is planning care for a client who has dysphagia and is at risk for aspiration.
Which of the following referrals should the nurse make?
(answer)- Speech-language pathologist
A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes
mellitus. Which of the following actions should the nurse take prior to performing the
teaching? (select all that apply)
(answer)- - Establish the client's learning needs
- Determine the client's literacy level
- Evaluate the client's readiness for learning
- Identify the client's learning style
A nurse is preparing to notify the provider about a change in a client's status. Which of
the following information should the nurse plan to include in the "background" portion of
the SBAR communication tool?
(answer)- Previous treatments
A nurse is providing discharge teaching to a client who has a new prescription for home
oxygen therapy utilizing a compressed oxygen system. Which of the following
statements by the client indicates an understanding of the teaching?
(answer)- "I will store oxygen tanks in an upright position"
, A nurse is caring for a client who has terminal cancer. The client begins to cry and says,
"I am afraid of dying." Which of the following responses should the nurse make?
(answer)- "It must me a very difficult time for you."
A nurse is assessing a client's coping skills. Which of the following should the nurse
identify as an internal stressor?
(answer)- Fear of medical test results
A nurse is performing postmortem care for an older client who had just died. Which of
the following actions should the nurse take?
(answer)- Identify the client using two identifiers
A nurse has administered 5 mL of medication to a client via NG tube. Then used 30 mL
of water to flush the tue both before and after the instillation. the nurse should document
which of the following amounts as liquid intake for the client?
(answer)- 65 mL
A nurse is performing a family assessment for a client who has recently developed
paraplegia following a stroke. Which of the following actions should the nurse take first?
(answer)- Determine how the client views the concept of family
A nurse is caring for a client who reports having insomnia due to increased stress.
Which of the following actions should the nurse take first?
(answer)- Determine the source of the client's stress
A nurse is caring for a client who had a stroke and is immobile. Which of the following
actions should the nurse take to maintain the client's skin integrity?
(answer)- Use an alcohol-free barrier product
A nurse receives a telephone prescription form the provider, who states, "four milligrams
of morphine diluted with 5 milliliters of sterile water intravenous each morning at nine
o'clock before client dressing changes." Which of the following entries by the nurse
indicates correct transcription of the prescription?
(answer)- Morphine 4 mg IV bolus daily at 0900 before dressing change, dilute
medication with 5 mL of sterile water
A nurse in a long-term care facility is planning to use therapeutic tough for a group of
selected clients who have chronic pain. The nurse should identify that the use of
therapeutic touch is contraindicated for which of the following patients?
(answer)- A client who has chronic back pain and a history of physical maltreatment
A nurse is preparing to delegate task for multiple clients at the beginning of the shift.
Which of the following tasks should the nurse delegate to an assistive personnel (AP)?
(answer)- Assist a client with ambulation