The nurse provides sliding scale insulin administration instructions to an adult who was recently diagnosed with diabetes mellitus. The client demonstrates an understanding of the instructions provided by performing the procedure in which order? (Arrange with the first on top and the last on the bottom.)

Obtain blood glucose level.

Verify the insulin prescription.

Draw insulin into insulin syringe.

Cleanse the selected site.

Answer and Explanation

The Correct Answer is B,A,D,C

1. B. Verify the insulin prescription: The first step is to verify the prescription to ensure the correct type and dose of insulin before administering it. This ensures one is following the appropriate instructions.

2. A. Obtain blood glucose level: The next step is to check the client's blood glucose level to determine the amount of insulin needed based on the sliding scale.

3. D. Cleanse the selected site: After obtaining the blood glucose level, the next step is to prepare the injection site by cleaning it properly to prevent infection.

4. C. Draw insulin into insulin syringe: Finally, drawing the appropriate amount of insulin into the syringe, based on the sliding scale and the blood glucose level, to administer the injection.

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Correct Answer is B

Explanation

A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet: Documenting a previous reading does not reflect the client’s current condition and can be misleading in decision-making. Vital signs should be based on real-time assessment.

B. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed: The popliteal site is appropriate for measuring blood pressure when the arms are inaccessible. Flexing the knee while the client is supine allows better access to the artery and enables accurate assessment of blood pressure in this situation.

C. Document why the blood pressure cannot be accurately measured at the present time: While documentation is necessary if no alternative is available, the nurse must first exhaust appropriate options for obtaining a blood pressure before choosing to omit it.

D. Estimate the blood pressure by assessing the pulse volume of the client's radial pulses: Pulse volume gives a very rough estimate of perfusion but does not provide an accurate or objective blood pressure measurement. This method lacks precision.

A. Squeeze the nipple base to introduce milk into the mouth. B. Position the baby in the left lateral position after feeding. C. Alternate milk with water during the feeding. D. Hold the newborn in an upright position.

Correct Answer is D

Explanation

A. Squeeze the nipple base to introduce milk into the mouth: This may increase the risk of aspiration if milk flows too rapidly, especially in infants with cleft lips who have difficulty forming a tight seal and managing suck-swallow coordination effectively.

B. Position the baby in the left lateral position after feeding: Although side-lying may aid digestion in some cases, it’s not the priority after feeding a newborn with cleft lip. Upright positioning is safer and helps reduce aspiration risk.

C. Alternate milk with water during the feeding: Offering water during feedings is not recommended for newborns, as it can displace nutritional intake and may disrupt electrolyte balance. It also offers no benefit for cleft lip management.

D. Hold the newborn in an upright position: This reduces the risk of aspiration by improving control of milk flow and promoting effective swallowing. It is the safest and most effective position for feeding an infant with cleft lip.

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Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

The nurse is reviewing the plan of care for a newly admitted client who is intoxicated on admission. Which findings should the nurse include as indicators to begin implementing the detoxification medication protocol?

The nurse is caring for a client who had surgery 1 day ago and is receiving a continuous infusion of fentanyl through an epidural catheter. Which intervention should the nurse perform first?

The nurse is setting up the equipment to assist with a sigmoidoscopy while the practical nurse (PN) positions the client in a flat prone position. Which action should the nurse implement?

Exhibits The nurse reviews the prescriptions and plans initial steps for caring for the client. Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

The healthcare provider prescribes dalteparin 200 units/kg SUBQ once a day for a client who weighs 154 lb. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

A pre-school age child with a congenital heart defect is brought to the clinic by the parent because of a fever and an earache. During the assessment, the parent asks the nurse why the child is at the 5th percentile for weight and height for age. Which response is best for the nurse to provide?

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?