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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. - Correct 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 planning care for a client who has dysphagia and is at risk for
aspiration. Which of the following referrals should the nurse make? - Correct
Answer -Speech-language pathologist
A nurse is assessing a client who wears partial dentures and reports mouth
pain. Which of the following actions should the nurse take? - Correct Answer
-Advise the client to rinse their mouth and dentures after each meal.
thoracentesis post procedure? - Correct Answer -Position the client on the
unaffected side.The nurse should position the client on the unaffected side to
help facilitate expansion of the affected lung.
Maintain the head of the bed at 45°.MY ANSWERSome facility protocols
recommend that the nurse should raise the head of the bed to 30° for at
least 30 min to facilitate expansion of the affected lung and ease of
breathing.
Measure the client's abdominal girth at the level of the umbilicus.The nurse
should measure the client's abdominal girth following an abdominal
paracentesis, rather than a thoracentesis.
Leave the puncture site open to air.The nurse should apply a small, sterile
dressing over the puncture site.
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) - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct 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? - Correct
Answer -Determine the source of the client's stress