a nurse is preparing to administer a dose of insulin which of the following should the nurse do first
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 B

1. A nurse is preparing to administer a dose of insulin. Which of the following should the nurse do first?

Correct answer: B

Rationale: The correct answer is to verify the client's blood glucose level first before administering insulin. This step is crucial to determine the appropriate dose of insulin based on the client's current blood glucose level. Checking the expiration date (Choice A) is important but not the first step in this scenario. Obtaining the client's weight (Choice C) is not directly related to the immediate administration of insulin. Assessing for signs of hypoglycemia (Choice D) should be done after administering insulin to monitor for potential side effects or adverse reactions.

2. A nurse observes an assistive personnel (AP) providing care to a child who is in skeletal traction. Which of the following actions requires intervention?

Correct answer: C

Rationale: The correct answer is C. Placing weights on the child's bed can alter the traction, which must remain constant to be effective. This action requires immediate intervention to prevent harm. Providing a high-protein snack (Choice A) is appropriate for the child's nutritional needs. Assisting the child to reposition (Choice B) helps prevent complications such as pressure ulcers. Massaging pressure points (Choice D) can help promote circulation and prevent skin breakdown. However, altering the traction by placing weights on the bed can be detrimental to the child's condition and must be corrected promptly.

3. A client newly diagnosed with osteoporosis is being taught by a nurse about preventing complications. Which food should the nurse recommend?

Correct answer: C

Rationale: Oatmeal is an excellent recommendation for clients with osteoporosis due to its richness in fiber and nutrients, making it a heart-healthy and bone-friendly choice. Fried chicken (Choice A) is high in unhealthy fats and lacks the nutrients needed for bone health. Whole milk (Choice B) contains calcium but can be high in saturated fats, which may not be the best choice for individuals with osteoporosis. Bacon (Choice D) is high in saturated fats and sodium, which can have negative effects on bone health and overall well-being.

4. A nurse is teaching a client about the use of nitrofurantoin. Which of the following should be included?

Correct answer: A

Rationale: The correct answer is A. Nitrofurantoin can cause a harmless brown discoloration of urine. Choice B is also correct as it should be taken with food to enhance absorption. Choice C is incorrect as nitrofurantoin does have side effects, such as gastrointestinal disturbances. Choice D is incorrect as nitrofurantoin is not recommended during the last month of pregnancy due to potential risks to the fetus.

5. A client with a new ileostomy is receiving discharge instructions from a nurse. Which statement indicates the client understands the teaching?

Correct answer: B

Rationale: The correct answer is B. Ileostomy stomas typically drain liquid continuously, unlike colostomies. This continuous drainage is a key characteristic that clients should understand postoperatively. Choice A is incorrect because ensuring medications are enteric-coated is not directly related to understanding ileostomy care. Choice C is incorrect as changing the pouch system every two weeks is not a general rule and may vary depending on the individual's needs. Choice D is incorrect because the stoma size can change during the healing process and clients should be informed about this possibility.

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