Questions 150

NCLEX-RN

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Extract:


Question 1 of 5

Place the following steps for mixing NPH and regular insulin in the proper sequential order from # 1 to # 6 below. #1 - Prep the top of the shorter acting insulin with an alcohol swab #2 - Inject air that is equal to the ordered dosage of the shorter acting insulin using the same insulin syringe. #3 - Withdraw the ordered dosage of the shorter acting insulin using the same insulin syringe. #4 - Prep the top of the longer acting insulin vial with an alcohol swab. #5 - Inject air that is equal to the ordered dosage of the longer acting insulin using the insulin syringe. #6 - Withdraw the ordered dosage of the longer acting insulin using the same insulin syringe.

Correct Answer: A

Rationale: The correct sequence is: 1) Prep short-acting insulin vial, 2) Inject air into short-acting vial, 3) Withdraw short-acting insulin, 4) Prep long-acting insulin vial, 5) Inject air into long-acting vial, 6) Withdraw long-acting insulin to avoid contamination.

Question 2 of 5

A client is prescribed amiloride 10 mg orally daily for the treatment of hypertension. Which instruction should the nurse give the client regarding its administration?

Correct Answer: A

Rationale: Amiloride is a potassium-retaining diuretic used to treat edema or hypertension. A daily dose should be taken in the morning to avoid nocturia. Increased blood pressure is not a reason to hold the medication, and it may be an indication for its use. Sodium should be restricted if used as an antihypertensive. The dose should be taken with food to increase bioavailability.

Question 3 of 5

The nurse is teaching a client who is taking insulin about the signs of diabetic ketoacidosis, which include:

Correct Answer: A

Rationale: Kussmaul's respirations (rapid, deep breathing) are a hallmark of diabetic ketoacidosis as the body compensates for acidosis. Excessive hunger is more typical of hypoglycemia, and dry skin or hypertension are less specific.

Question 4 of 5

A client with the diagnosis of leukemia is receiving chemotherapy. When the registered nurse (RN) notes that the white blood cell (WBC) count is 4000 mm^3 (4 x 10^9/L), the new nurse caring for the client is informed about the results. Which intervention identified by the new nurse indicates a need for further teaching?

Correct Answer: D

Rationale: Padding the side rails and removing all hazardous and sharp objects from the environment would be instituted if the client is at risk for bleeding. This client is at risk for infection. When the WBC count is less than 5000 mm^3 (5 x 10^9/L), visitors should be screened for the presence of infection, and any visitors or staff with colds or respiratory infections should not be allowed in the client's room. All live plants, flowers, and stuffed animals are removed from the client's room. The client is placed on a low-bacteria diet that excludes raw fruits and vegetables.

Question 5 of 5

The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see fi gure). The nurse should:

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Correct Answer: D

Rationale: The nurse is wearing protective personnel equipment appropriately for suctioning the client: goggles, gown and respirator mask. It is not necessary to wear a powered air purifying respirator face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.

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