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Questions 164

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Extract:

Exhibit 1
Medication administration record

Allergies: No known drug allergies

Medication Time
Insulin NPH: 75 units subcutaneously, twice daily 0800, 2000
Insulin lispro: sliding scale dosing, before meals and at bedtime 0800, 1130, 1730, 2100

Exhibit 2
Laboratory results and reference ranges

Sodium
136-145 mEq/L
(136-145 mmol/L) 141 mEq/L
(141 mmol/L)
Potassium
3.5-5.0 mEq/L
(3.5-5.0 mmol/L) 3.0 mEq/L
(3.0 mmol/L)
Glucose (fasting)
70-110 mg/dL
(3.9-6.1 mmol/L) 328 mg/dL
(18.2 mmol/L)





Question 1 of 5

The nurse is preparing to administer medications scheduled for 0800 to a client with type 1 diabetes mellitus. After reviewing the client's morning laboratory test results, which of the following actions would be a priority for the nurse to take?

Correct Answer: B

Rationale: Abnormal lab results (e.g., severe hypo/hyperglycemia) require provider notification to adjust treatment. Administering insulin, checking ketones, or rechecking glucose are secondary without specific lab values.

Extract:


Question 2 of 5

A nurse assigns a task to unlicensed assistive personnel. They state, 'We can’t do that.' Which is the best initial response for the nurse to make?

Correct Answer: A

Rationale: Asking the reason clarifies whether the refusal is due to scope, training, or other issues, promoting collaboration. Performing the task, ignoring, or lecturing avoids addressing the root cause.

Question 3 of 5

A practical nurse (PN) is assigned to care for a newborn with a neural tube defect. Which dressing, if applied by the PN, would need no further intervention by the charge nurse?

Correct Answer: B

Rationale: Before surgical closure, the sac is prevented from drying by the application of a sterile, moist, nonadherent dressing over the defect. Dressings are changed frequently to keep them moist.

Question 4 of 5

The nurse is talking with a postpartum client about resuming sexual activity after childbirth. The client had an uncomplicated vaginal delivery 2 weeks ago. Which statement by the client requires follow-up?

Correct Answer: A

Rationale: Ovulation can occur before menses returns, so condoms are needed to prevent pregnancy. Vaginal dryness is common, and feeding before sex reduces interruptions, both correct.

Question 5 of 5

Which type of accidental poisoning would the nurse expect to occur in children under age 6?

Correct Answer: A

Rationale: Oral ingestion. Young children are most likely to ingest toxic substances due to their exploratory behavior.

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