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Questions 164

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Extract:


Question 1 of 5

The nurse and unlicensed assistive personnel (UAP) are caring for a client who is experiencing an acute episode of Ménière disease. Which action by the UAP would require the nurse to intervene?

Correct Answer: C

Rationale: Raising all side rails during an acute Ménière's episode (vertigo, nausea) increases fall risk if the client attempts to climb over them. Other actions (assisting to commode, dimming lights, turning off TV) reduce stimulation and promote safety.

Question 2 of 5

A mother asks the nurse if she should be concerned about her child's tendency to stutter. What assessment data will be most useful in counseling the parent?

Correct Answer: A

Rationale: Age of the child. Stuttering is often a normal part of language development in preschoolers, making age a critical factor.

Extract:

Medication administration record
Allergies: No Known Allergies
Sliding scale blood glucose levels, regular insulin dose
<150 mg/dL (<8.3 mmol/L), O units
150-199 mg/dL (8.3-11.0 mmol/L), 2 units
200-249 mg/dL (11.1-13.8 mmoV/L), 4 units
250-299 mg/dL (13.9-16.6 mmol/L), 6 units
≥300 mg/dL (≥16.7 mmol/L), 8 units and notify health care provider


Question 3 of 5

A client with type 1 diabetes has a prescription for 30 units of insulin glargine at bedtime. Fingerstick blood glucose measurements are prescribed before meals and at bedtime with regular insulin based on a sliding scale. At 9 PM, the client's blood glucose measurement is 180 mg/dL (10.0 mmol/L). What action should the nurse take?

Correct Answer: B

Rationale: The sliding scale indicates 2 units of regular insulin for a glucose of 180 mg/dL. Glargine, a long-acting insulin, should be given as prescribed (30 units). Glargine cannot be mixed with regular insulin in the same syringe due to differing pH levels, so separate injections are required.

Extract:


Question 4 of 5

The nurse in an ambulatory care center is reinforcing teaching to a client with a diagnosis of persistent depressive disorder (dysthymia) about the appropriate use of bupropion hydrochloride sustained release. What statement by the client indicates a need for further teaching?

Correct Answer: B

Rationale: Bupropion sustained-release tablets must not be cut, as this disrupts the controlled-release mechanism, risking side effects. Other statements are correct: mood changes require reporting, missed doses shouldn't be doubled, and therapeutic effects take weeks.

Question 5 of 5

A client with glaucoma has been prescribed Timoptic (timolol) eye drops. Timoptic should be used with caution in the client with a history of:

Correct Answer: C

Rationale: Timolol, a beta-blocker, can exacerbate emphysema by causing bronchoconstriction. Diabetes , ulcers , and pancreatitis are not contraindications.

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