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1. A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching?
- A. The patient always carries hard candies when engaging in exercise.
- B. The patient goes for a vigorous walk when his glucose is 200 mg/dL.
- C. The patient has a peanut butter sandwich before going for a bicycle ride.
- D. The patient increases daily exercise when ketones are present in the urine.
Correct answer: D
Rationale: The correct answer is D because increasing exercise when ketones are present in the urine is inappropriate and potentially dangerous for a patient with type 1 diabetes. This behavior can worsen the ketosis and lead to further complications. Choices A, B, and C demonstrate appropriate self-management strategies for a patient with type 1 diabetes. Carrying hard candies during exercise can help prevent hypoglycemia, going for a walk with a glucose level of 200 mg/dL can help lower blood sugar, and having a snack before physical activity can provide necessary energy.
2. A nurse is planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the adolescent's visitors.
- B. Select the adolescent's food choices.
- C. Encourage the adolescent's guardian to assist with personal hygiene.
- D. Allow the adolescent to make decisions regarding their daily routine.
Correct answer: C
Rationale: The correct answer is C because after a lumbar laminectomy, the adolescent may need assistance with personal hygiene due to limited mobility and pain. Encouraging the guardian to assist with personal hygiene ensures proper care and prevents complications. Choice A is incorrect as limiting visitors may affect the adolescent's emotional well-being and support system. Choice B is incorrect as the adolescent should have autonomy in selecting their food choices as long as they align with their dietary restrictions post-surgery. Choice D is incorrect as the adolescent may need guidance and support in decision-making during the postoperative period.
3. 1. Which patient action indicates good understanding of the nurse�s teaching about administration of aspart (NovoLog) insulin?
- A. The patient avoids injecting the insulin into the upper abdominal area
- B. The patient cleans the skin with soap and water before insulin administration.
- C. The patient stores the insulin in the freezer after administering the prescribed dose.
- D. The patient pushes the plunger down while removing the syringe from the injection site
Correct answer: B
Rationale:
4. In preparation for a client's procedure with a latex allergy, which of the following precautions should the nurse take?
- A. Ensure sterilization of nondisposable items with ethylene oxide.
- B. Wear hypoallergenic latex gloves that do not contain powder.
- C. Cleanse latex ports on IV tubing with chlorhexidine before injecting medication.
- D. Wrap monitoring cords with stockinette and tape them in place.
Correct answer: B
Rationale: The correct answer is B: Wear hypoallergenic latex gloves that do not contain powder. When a client has a latex allergy, it is crucial to avoid direct contact with latex-containing products to prevent an allergic reaction. Choosing hypoallergenic latex gloves that are powder-free reduces the risk of the client being exposed to latex allergens. Option A is incorrect because using ethylene oxide for sterilization does not directly address the client's latex allergy. Option C is incorrect because cleansing latex ports with chlorhexidine does not eliminate the risk of latex exposure. Option D is incorrect as it does not specifically address the issue of latex allergy during the procedure.
5. A client who is nonambulatory notifies the nurse that their trash can is on fire. After the nurse confirms the presence of the fire, which of the following actions should the nurse take next?
- A. Activate the emergency fire alarm.
- B. Extinguish the fire.
- C. Evacuate the client.
- D. Confine the fire.
Correct answer: D
Rationale: In this situation, the nurse's priority should be to confine the fire. By confining the fire, the nurse can prevent it from spreading further and causing more harm. Activating the emergency fire alarm (choice A) is important but should come after confining the fire. Extinguishing the fire (choice B) might not be safe for the nurse to do without proper equipment and training. Evacuating the client (choice C) can be considered once the fire is confined to ensure the client's safety.
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