Medication
The nurse is preparing to administer NPH insulin 10 units and regular insulin 5 units by mixing in the same syringe. What is the best way to prevent contamination of the regular insulin with the NPH insulin?
Inject 10 units of air into the space above the NPH insulin followed by injecting 5 units of air into the space above the regular insulin.
The nurse is monitoring a client with diabetes mellitus for signs of hypoglycemia. Which manifestations are associated with this complication?
1.
Slow pulse; lethargy; warm, dry skin
2.
Elevated pulse; lethargy; warm, dry skin
3.
Elevated pulse; shakiness; cool, clammy skin
4.
Slow pulse, confusion, increased urine output
3.
Elevated pulse; shakiness; cool, clammy skin
Which safeguard should the nurse take to ensure accuracy of a telephone order?
Repeat the order to the prescriber
The nurse caring for patients in a long-term care facility knows that there are factors that place certain patients at a higher risk for falls. Which patients would the nurse consider to be in this category? Select all that apply.
a. A patient who is older than 50
b. A patient who has already fallen twice
c. A patient who is taking antibiotics
d. A patient who experiences postural hypotension
e. A patient who is experiencing nausea from chemotherapy
f. A 70-year-old patient who is transferred to long-term care
b, d, f. Risk factors for falls include age over 65 years, documented history of falls, postural hypotension, and unfamiliar environment. A medication regimen that includes diuretics, tranquilizers, sedatives, hypnotics, or analgesics is also a risk factor, not chemotherapy or antibiotics.
The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which client complaints would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply.
1.
Tremors
2.
Anorexia
3.
Irritability
4.
Nervousness
5.
Hot, dry skin
6.
Muscle cramps
Tremors, Irritability, Nervousness
The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign, if exhibited in the client, would indicate hyperglycemia?
1.
Polyuria
2.
Diaphoresis
3.
Hypertension
4.
Increased pulse rate
1.
Polyuria
2.
Shakiness
3.
Palpitations
4.
Blurred vision
5.
Lightheadedness
6.
Fruity breath odor
1.
Polyuria
The nurse is developing a hospital policy on guidelines for telephone and verbal prescriptions. Which guidelines should the nurse include in the policy? Select all that apply:
1. Clarify any questions with the health care provider
2. Repeat the prescribed prescriptions back to the health care provider
3. Avoid using abbreviations such as TO (telephone order) because they are never acceptable
4. Remember that verbal prescriptions are never acceptable; the health care provider must document the prescription
5. Cosigning the prescription by the health care provider is not necessary if the nurse repeats the prescription for verification
6. Documentation of the name of the health care provider giving the prescription is not necessary if the health care provider is the client's primary health care provider
1. Clarify any questions with the health care provider
2. Repeat the prescribed prescriptions back to the health care provid
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription?
1.
Endotracheal intubation
2.
100 units of NPH insulin
3.
Intravenous infusion of normal saline
4.
Intravenous infusion of sodium bicarbonate
3. Intravenous solution of normal saline.
Rationale:
The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places highest priority on which client problem?
1.
Lack of knowledge
2.
Inadequate fluid volume
3.
Compromised family coping
4.
Inadequate consumption of nutrients
2.
Inadequate fluid volume
A nurse is discharging a patient from the hospital following a heart stent procedure. The patient asks to see and copy his medical record. What is the nurse's best response?
a. "I'm sorry, but patients are not allowed to copy their medical records."
b. "I can make a copy of your record for you right now."
c. "You can read your record while you are still a patient, but copying records is not permitted according to HIPAA rules."
d. "I will need to check with our records department to get you a copy.
d. "I will need to check with our records department to get you a copy.
According to HIPAA, patients have a right to see and copy their health record; update their health record; get a list of the disclosures a health care institution has made independent of disclosures made for the purposes of treatment, payment, and health care operations; request a restriction on certain uses or disclosures; and choose how to receive health information. The nurse should be aware of facility policies regarding the patient’s right to access and copy records.
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperglycemic hyperosmolar state (HHS) is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription?
1.
Endotracheal intubation
2.
100 units of NPH insulin
3.
Intravenous infusion of normal saline
4.
Intravenous infusion of sodium bicarbonate
3. Intravenous solution of normal saline.
Rationale:
The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply.
1.
Polyuria
2.
Shakiness
3.
Palpitations
4.
Blurred vision
5.
Lightheadedness
6.
Fruity breath odor
2.
Shakiness
3.
Palpitations
5.
Lightheadedness
A friend of a nurse calls and tells the nurse that his girlfriend's father was just admitted to the hospital as a patient, and he wants the nurse to provide information about the man's condition. The friend states, "Sue seems unusually worried about her dad, but she won't talk to me and I want to be able to help her." What is the best initial response the nurse should make?
a. "You shouldn't be asking me to do this. I could be fined or even lose my job for disclosing this information."
b. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks."
c. "Because of HIPAA, you shouldn't be asking for this information unless the patient has authorized you to receive it! This could get you in trouble!"
d. "Why do you think Sue isn't talking about her worries?
b. "Sorry, but I'm not able to give information about patients to the public—even when my best friend or a family member asks."
The nurse should immediately clarify what he or she can and cannot do. Since the primary reason for refusing to help is linked to the responsibility to protect patient privacy and confidentiality,