verified answers
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. Ans✔✔ -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.
To mix insulin from two vials in the same syringe, the nurse should first
draw up a volume of air equal to the volume of insulin from the
intermediate-acting insulin vial. The nurse should then inject the volume
of air equal to the amount of insulin to withdraw from the intermediate-
acting insulin vial, making sure the needle does not touch the insulin.
Next, the nurse should inject the volume of air equal to the insulin dose
from the short-acting insulin vial. Then, the nurse should withdraw the
prescribed amount of insulin from the short-acting insulin vial. Lastly,
,the nurse should withdraw the prescribed amount of insulin from the
intermediate-acting insulin vial. The insulins are now mixed and ready
to administer.
A nurse is assessing a client who wears partial dentures and reports
mouth pain. Which of the following actions should the nurse take?
Provide the client with an alcohol-based mouthwash.
Instruct the client to brush their remaining teeth with a firm toothbrush.
Advise the client to rinse their mouth and dentures after each meal.
Swab the client's mouth with lemon-glycerin sponges at bedtime.
Ans✔✔ -Advise the client to rinse their mouth and dentures after each
meal.
The nurse should advise the client to rinse their mouth and dentures after
each meal to remove food and particles and to promote healing of gums
and oral mucosa.
The nurse should instruct the client to rinse their mouth four times each
day with mild rinses, such as normal saline or sodium bicarbonate
solution. The nurse should inform the client that mouthwashes
containing alcohol dry the oral mucosa and can irritate tissue.
,The nurse should instruct the client to brush their remaining teeth with a
soft toothbrush at least twice each day to reduce the risk for gum
abrasions.
The nurse should avoid using lemon-glycerin sponges because they can
cause erosion of the client's tooth enamel, dry the mucous membranes,
and increase the client's current discomfort.
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?
Ans✔✔ -Speech-language pathologist
The nurse should recommend a referral for a client who has dysphagia to
a speech-language pathologist. Clients who have dysphagia have
difficulty swallowing and are at risk for aspiration. The speech-language
pathologist can perform a swallow study to determine the extent of the
client's dysphagia and work with the client to develop new swallowing
techniques.
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) Ans✔✔ --
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
Establish the client's learning needs is correct. Prior to planning any
teaching session, the nurse should perform a comprehensive assessment
of the client's learning needs. This assessment incorporates information
from the client's history and physical assessment, current health
problems, understanding of and adherence to the prescribed treatment
plan, and support system. Determine the client's literacy level is correct.
Knowing the client's literacy level is an important factor in
communicating with the client and in delivering audiovisual
presentations and written materials. If the client cannot understand the
information the nurse presents, they will not learn. Evaluate the client's
readiness for learning is correct. The nurse should determine the client's
physical readiness (pain control), emotional readiness (acceptance of
diagnosis), and cognitive readiness (appropriate level of consciousness).
Identify the client's learning style is correct. The best way to learn varies
from client to client. Some people learn best by watching a
demonstration, while others thrive in a group setting, and others prefer to
read information on their own. In a group setting, the nurse should use a
variety of styles to accommodate most learners.
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?
Client's present condition
Questions for the provider regarding client care