Exhibits

It is 1800, and the client has a scheduled dose of insulin glargine due. The client has a regular diet tray ordered with 60 carbohydrates. The tray has not yet arrived in the room.

For each nursing action below, click to specify if the action is indicated, contraindicated or nonessential. Each row must have one option selected.

Give insulin lispro 4 units

Verify that the client can count carbohydrates

Mix the insulin lispro and insulin glargine in one syringe

Give insulin glargine 12 units

Answer and Explanation

The Correct Answer is {"A":{"answers":"B"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"A"}}

Give insulin lispro 4 units: Contraindicated - Insulin lispro is a rapid-acting insulin that should be given in relation to meal intake. Since the client's meal tray has not arrived, administering insulin lispro could lead to hypoglycemia.
Verify that the client can count carbohydrates: Nonessential - While it’s useful to know if a client can count carbohydrates, it’s not critical for administering scheduled long-acting insulin like insulin glargine.
Mix the insulin lispro and insulin glargine in one syringe: Contraindicated - Insulin glargine is a long-acting insulin and should not be mixed with other insulins in the same syringe.
Give insulin glargine 12 units: Indicated - Insulin glargine is a long-acting insulin that is typically given at a set time each day and is not dependent on immediate food intake, so it is appropriate to administer the scheduled dose.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D","E","F"]

Explanation

Monitor vital signs continuously: This is crucial to detect any further changes in heart rate or blood pressure, especially given the client’s history of symptomatic bradycardia and recent hypotensive episode following vancomycin administration.

Echocardiogram: This is appropriate post-pacemaker insertion to assess cardiac function and ensure the pacemaker is functioning properly.

Immunological:

Administer antihistamine: Given the client’s adverse reaction to vancomycin, which included hives, flushing, and itching, administering an antihistamine like diphenhydramine is appropriate.

Assess rash: Monitoring the progression or improvement of the rash will help evaluate the effectiveness of the interventions and the resolution of the allergic reaction.

Respiratory:

Assess lung sounds: It's important to evaluate the client’s respiratory status, especially given the shortness of breath reported post-operatively, which could indicate a reaction to the medication or a complication from the procedure.

Provide calm environment: This intervention helps in reducing anxiety and stress, which can exacerbate symptoms and impact cardiovascular and respiratory status.

A. Increased anxiety and nervousness have been reported by those taking feverfew. B. Those with allergies to chamomile, ragweed, or yarrow should not take feverfew. C. Abdominal pain, gas, nausea, vomiting, and diarrhea can occur when taking feverfew. D. Feverfew may interact with aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs).

Correct Answer is B

Explanation

A. While feverfew can cause gastrointestinal issues, increased anxiety and nervousness are not commonly reported side effects.
B. Feverfew may cause allergic reactions in individuals with sensitivities to related plants like chamomile, ragweed, or yarrow, making this information crucial for preventing allergic reactions.
C. Gastrointestinal side effects like abdominal pain, gas, nausea, vomiting, and diarrhea are possible but are not as critical as the risk of an allergic reaction.
D. Interaction with aspirin or NSAIDs is a concern but is secondary to the importance of avoiding feverfew in individuals with known allergies to similar plants.

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Body system	Potential nursing intervention
Cardiovascular	Monitor vital signs continuously Provide warmth Echocardiogram Defibrillator at bedside
Immunological	Administer steroid Assess rash IV fluids Administer antihistamine
Respiratory	Assess lung sounds Pain medication Provide calm environment Chest x-ray

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D","E","F"]

Explanation

A client who experiences migraine headaches reports having fewer headaches since using the herbal remedy feverfew. Which information is most important for the nurse to include in a teaching plan for this client?

Correct Answer is B

Explanation

Exhibits Review H and P, nurse's notes, laboratory values, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the mannitol administered, a non-therapeutic side effect, or an unrelated finding. Each row must have one option selected.

Exhibits Review H and P, nurse's notes, laboratory results, flow sheet, and prescriptions. Click to mark whether the assessment finding represents a therapeutic result of the minoxidil administered, a non-therapeutic side-effect, or an unrelated finding. Each row must have one option selected.

During a home visit, the nurse assesses a client with Alzheimer's disease who recently started a new prescription for rivastigmine. The caregiver reports that the client seems to be thinking more clearly but is not sleeping well at night. Which action should the nurse take?

A client is receiving miotics for the treatment of open-angle glaucoma. The nurse determines that a priority nursing problem is "risk for injury." This nursing problem is based on which etiology?

When preparing to apply a scheduled fentanyl transdermal patch, the nurse notes that the previously applied patch is intact on the client's upper back and the client denies pain. Which action should the nurse take?

Exhibits The nurse is preparing the client's plan of care. Select 4 findings that would indicate to the nurse that the administration of the vancomycin antibiotic would be safe to administer.

A client with a history of chronic obstructive pulmonary disease (COPD) receives a new prescription for an ipratropium inhaler. Which action indicates to the nurse that additional teaching is needed?

The nurse is administering sucralfate to a client with stomatitis secondary to chemotherapy. The client wants to take the medication after breakfast. How should the nurse respond?