Extract:

Question 1 of 5

A nurse is reinforcing teaching with a client who has a new prescription for insulin glargine. Which of the following statements should the nurse include?

A. You should shake the vial vigorously before drawing up the medication.B. You should administer this medication at the same time each day.C. This medication might cause you to feel shaky and sweaty during the night.D. You can mix this medication with short-acting insulin in the same syringe.

Correct Answer: B

Rationale: Insulin glargine requires consistent timing for steady blood sugar control. Shaking clouds it, hypoglycemia is rare at night with glargine, and it shouldn't be mixed.

Extract:

Nurses Notes
Day 1, 12:00:
Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child.
Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area.
Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse.
Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles, "I don't know. Ask them." Client's child states, "He gets confused sometimes. I can answer your questions."

Question 2 of 5

Nurses Notes Day 1, 12:00: Transferred to medical-surgical unit from emergency department (ED) for continued care following a closed reduction and immobilization of a fracture of the right arm. Accompanied by adult child. Client in visibly soiled night clothes with multiple stains, including what appears to be dried blood. Hair, teeth, and fingernails unclean. Strong body odor noted. Bruising of various stages noted around upper arms, back, shoulders, and neck area. Client is soft-spoken, speaks almost in a whisper, does not make eye contact with nurse. Client looks at their child before answering the nurse's questions and, when asked how the injury occurred, mumbles, 'I don't know. Ask them.' Client's child states, 'He gets confused sometimes. I can answer your questions.' The nurse is identifying tertiary prevention strategies to implement for this client. Select the three actions the nurse should take.

A. Insist that the client explain the reason for their bruises.B. Inform the client that their child is being abusive toward them.C. Report suspected maltreatment to the appropriate agency.D. Confront the client's child about the client's injuries.E. Ask the client how the fracture occurred.F. Conduct the interview with the client privately.

Correct Answer: C,E,F

Rationale: Reporting suspected abuse, asking about the fracture, and interviewing privately are tertiary prevention steps to address and mitigate harm. Insisting, informing, or confronting may escalate without evidence.

Extract:

Question 3 of 5

A nurse is collecting a health history from the guardian of a 4-year-old child. Which of the following statements by the guardian is the priority for the nurse to address?

A. My child still wets the bed at least two times per week.B. I have noticed that my child is withdrawn since we switched day care providers.C. I have a difficult time getting my child to eat green vegetables.D. My child continually asks me the same questions.

Correct Answer: B

Rationale: Withdrawal after a daycare change suggests emotional distress, a priority over bedwetting, picky eating, or repetitive questions, which are less urgent.

Question 4 of 5

A nurse is reinforcing teaching with a client who has a new prescription for atorvastatin. Which of the following statements should the nurse include?

A. You should take this medication with a high-fat meal.B. You might notice a decrease in your cholesterol levels within 2 days.C. This medication might cause muscle pain.D. You should avoid eating potassium-rich foods while taking this medication.

Correct Answer: C

Rationale: Atorvastatin can cause muscle pain (myopathy), a key side effect to report. It's taken regardless of meals, cholesterol drops take weeks, and potassium isn't restricted.

Question 5 of 5

A nurse is caring for a client who has a new prescription for ipratropium via metered-dose inhaler. Which of the following actions should the nurse take?

A. Instruct the client to hold their breath for 5 seconds after inhaling.B. Monitor the client for signs of tachycardia.C. Administer the medication every 2 hr.D. Check the client's oxygen saturation prior to administration.

Correct Answer: B

Rationale: Ipratropium can cause tachycardia, a side effect to monitor. Breath-holding is 10 seconds, dosing is typically 4-6 hr, and O2 sat isn't directly related.