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Questions 164

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Extract:


Question 1 of 5

The nurse is talking with the spouse of a client who is eligible for hospice care. The spouse states, 'I do not know if I can make this decision. What would you do?' Which of the following responses would be appropriate for the nurse to make?

Correct Answer: A

Rationale: The nurse should remain neutral and facilitate discussion about the client's values and preferences, helping the spouse make an informed decision without personal bias or directing to other resources prematurely.

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 2 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 3 of 5

The doctor has ordered Lovenox (enoxaparin) 20 mg subcutaneously daily. The medication is available as 60 mg per mL. The nurse should administer:

Correct Answer: C

Rationale: Calculate: 20 mg ÷ 60 mg/mL = 0.333 mL, rounded to 0.33 mL for accurate dosing of Lovenox.

Question 4 of 5

When teaching a client about the side effects of fluoxetine (Prozac), which of the following will the nurse include?

Correct Answer: C

Rationale: Diarrhea, dry mouth, weight loss, reduced libido. Commonly reported side effects for fluoxetine (Prozac) are diarrhea, dry mouth, weight loss and reduced libido.

Question 5 of 5

The nurse is caring for an adult being admitted with a head injury. The nurse plans to place the client in which position?

Correct Answer: C

Rationale: Semi-reclining (30-45 degrees) reduces intracranial pressure in head injury by promoting venous drainage, unlike prone, supine, or upright positions.

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