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Questions 158

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Question 1 of 5

The nurse is teaching a 10-year-old insulin-dependent diabetic how to administer insulin. Which one of the following steps must be taught for insulin administration?

Correct Answer: B

Rationale: Sites for injection need to be rotated, including abdominal sites, to enhance insulin absorption. The pinch technique is the most effective method for obtaining skin tightness to allow easy entrance of the needle to subcutaneous tissues. Massaging the site of injection facilitates absorption of the insulin. Changing the needle will break the sterility of the system. It has become acceptable practice to reuse disposable needles and syringes for 3-7 days.

Question 2 of 5

The client at 34 weeks gestation is admitted with a diagnosis of gestational hypertension. Which assessment finding requires immediate intervention?

Correct Answer: C

Rationale: Absence of deep tendon reflexes in gestational hypertension suggests magnesium toxicity (if receiving magnesium sulfate) or severe neurological complications requiring immediate intervention. The other findings while concerning are less urgent.

Question 3 of 5

The nurse is caring for a client post-thyroidectomy. Which assessment finding requires immediate intervention?

Correct Answer: B

Rationale: Tingling in the fingers suggests hypocalcemia due to parathyroid gland damage, risking tetany or seizures, requiring immediate intervention. Pain (
A), hoarseness (
C), and mild fever (
D) are expected post-op.

Question 4 of 5

The nurse is caring for a client with a history of a pneumothorax who is being discharged. The nurse should teach the client to:

Correct Answer: C

Rationale: Chest pain post-pneumothorax may indicate recurrence or complications, requiring immediate reporting. Heavy lifting and swimming are restricted, and sleeping position is not critical.

Question 5 of 5

A client has renal failure. Today's lab values indicate he has an elevated serum potassium. What additional priority information does the nurse need to obtain?

Correct Answer: B

Rationale: The level of consciousness is not affected by elevated potassium levels. An electrocardiogram (EKG) can tell the nurse whether this client is experiencing any cardiac dysfunction or arrhythmias related to the elevated potassium level. Measurement of the urine output is not a priority nursing action at this time. The client's serum potassium values for the past several days may provide information about his renal function, but they are not a priority at this time.

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