Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
To prevent lipodystrophy in a client receiving insulin therapy, what should the nurse instruct the client to do?
A. Inject the insulin syringe at a 90-degree angle.
Injecting the insulin syringe at a 90-degree angle is a technique used to ensure that the insulin is delivered into the subcutaneous tissue. However, this does not specifically prevent lipodystrophy.
B. Avoid the deltoid when injecting the insulin.
Avoiding the deltoid when injecting insulin is not typically a recommendation for preventing lipodystrophy. Insulin is usually injected into the fatty tissue just under the skin in the abdomen, thighs, buttocks, or upper arms.
C. Rotate injection sites correctly.
Rotating injection sites correctly is a key strategy for preventing lipodystrophy. Lipodystrophy refers to abnormal changes in the fat tissue under the skin and can be caused by repeatedly injecting insulin into the same spot.
D. Massage the injection site.
Massaging the injection site is not typically recommended as it can cause the insulin to be absorbed too quickly.
This question is an excerpt from Nurse Dive's nursing test bank - Ati Med Surg Nurs 200 Proctored Exam Roxoborouh Memorial College. Take the full exam now
Full Explanation
Choice A rationale
Injecting the insulin syringe at a 90-degree angle is a technique used to ensure that the insulin is delivered into the subcutaneous tissue. However, this does not specifically prevent lipodystrophy.
Choice B rationale
Avoiding the deltoid when injecting insulin is not typically a recommendation for preventing lipodystrophy. Insulin is usually injected into the fatty tissue just under the skin in the abdomen, thighs, buttocks, or upper arms.
Choice C rationale
Rotating injection sites correctly is a key strategy for preventing lipodystrophy. Lipodystrophy refers to abnormal changes in the fat tissue under the skin and can be caused by repeatedly injecting insulin into the same spot.
Choice D rationale
Massaging the injection site is not typically recommended as it can cause the insulin to be absorbed too quickly.
Similar Questions
The nurse is preparing to administer an aminoglycoside antibiotic to a client admitted with a diagnosis of acute diverticulitis.
What is the priority nursing action?
A. Monitor the peak level of the antibiotic.
Monitoring the peak level of the antibiotic is important, but it is not the priority nursing action. Peak levels are typically drawn after the drug has been administered and are used to assess whether the dosage is sufficient.
B. Assess the client’s vital signs.
Assessing the client’s vital signs is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
C. Obtain a serum trough level.
Obtaining a serum trough level is the priority nursing action. Trough levels are drawn just before the next dose of the drug is due and are used to assess whether the dosage is safe.
D. Ask the client about drug allergies.
Asking the client about drug allergies is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
Full Explanation
Choice A rationale
Monitoring the peak level of the antibiotic is important, but it is not the priority nursing action. Peak levels are typically drawn after the drug has been administered and are used to assess whether the dosage is sufficient.
Choice B rationale
Assessing the client’s vital signs is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
Choice C rationale
Obtaining a serum trough level is the priority nursing action. Trough levels are drawn just before the next dose of the drug is due and are used to assess whether the dosage is safe.
Choice D rationale
Asking the client about drug allergies is an important part of nursing care, but it is not the priority action when preparing to administer an aminoglycoside antibiotic.
A client is receiving trimethoprim-sulfamethoxazole.
What information should the nurse include in the teaching about this medication?
A. Increase fluid intake to 3 to 4 liters per 24 hours.
Trimethoprim-sulfamethoxazole is an antibiotic used to treat or prevent bacterial infections. One of the key instructions for patients taking this medication is to increase fluid intake to 3 to 4 liters per 24 hours. This is because the medication can crystallize in the urine, which can lead to kidney stones or damage if the patient is not adequately hydrated.
B. Spend some time in the sun to improve drug metabolism.
Spending time in the sun does not improve the metabolism of trimethoprim-sulfamethoxazole. In fact, the medication can make the skin more sensitive to the sun, increasing the risk of sunburn.
C. Take Kaopectate daily to prevent diarrhea.
Taking Kaopectate daily to prevent diarrhea is not a standard instruction for patients taking trimethoprim-sulfamethoxazole. Diarrhea can be a side effect of the medication, but it should be managed under the guidance of a healthcare provider.
D. Take the drug every morning at the same time as hydrochlorothiazide.
There is no specific instruction to take trimethoprim-sulfamethoxazole every morning at the same time as hydrochlorothiazide. The timing of medication administration should be determined by the healthcare provider based on the patient’s overall treatment plan.
Full Explanation
Choice A rationale
Trimethoprim-sulfamethoxazole is an antibiotic used to treat or prevent bacterial infections. One of the key instructions for patients taking this medication is to increase fluid intake to 3 to
4 liters per 24 hours. This is because the medication can crystallize in the urine, which can lead to kidney stones or damage if the patient is not adequately hydrated.
Choice B rationale
Spending time in the sun does not improve the metabolism of trimethoprim-sulfamethoxazole. In fact, the medication can make the skin more sensitive to the sun, increasing the risk of sunburn.
Choice C rationale
Taking Kaopectate daily to prevent diarrhea is not a standard instruction for patients taking trimethoprim-sulfamethoxazole. Diarrhea can be a side effect of the medication, but it should be managed under the guidance of a healthcare provider.
Choice D rationale
There is no specific instruction to take trimethoprim-sulfamethoxazole every morning at the same time as hydrochlorothiazide. The timing of medication administration should be determined by the healthcare provider based on the patient’s overall treatment plan.
A newly diagnosed diabetic client is 24 hours post-op following abdominal surgery.
The 0700 blood glucose level is 200 mg/dl and the nurse administers 4 units of insulin aspart subcutaneously per the prescribed sliding scale.
When should the nurse first assess the client for signs and symptoms of hypoglycemia?
A. 0800
Hypoglycemia, or low blood sugar, can occur after insulin administration. However, the onset of hypoglycemia is not immediate. Insulin aspart, a rapid-acting insulin, has a peak action time of approximately 1-3 hours after administration. Therefore, assessing the patient for signs and symptoms of hypoglycemia at 0800, one hour after administration, may be too early.
B. 0730
Assessing the patient for signs and symptoms of hypoglycemia at 0730, 30 minutes after insulin administration, is too early. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
C. 1130
Assessing the patient for signs and symptoms of hypoglycemia at 1130, four and a half hours after insulin administration, may be too late. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
D. 1000
Assessing the patient for signs and symptoms of hypoglycemia at 1000, three hours after insulin administration, is within the peak action time of insulin aspart. Therefore, this is the most appropriate time to start assessing the patient for signs and symptoms of hypoglycemia.
Full Explanation
Choice A rationale
Hypoglycemia, or low blood sugar, can occur after insulin administration. However, the onset of hypoglycemia is not immediate. Insulin aspart, a rapid-acting insulin, has a peak action time of approximately 1-3 hours after administration. Therefore, assessing the patient for signs and symptoms of hypoglycemia at 0800, one hour after administration, may be too early.
Choice B rationale
Assessing the patient for signs and symptoms of hypoglycemia at 0730, 30 minutes after insulin administration, is too early. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
Choice C rationale
Assessing the patient for signs and symptoms of hypoglycemia at 1130, four and a half hours after insulin administration, may be too late. The peak action time of insulin aspart is approximately 1-3 hours after administration. Therefore, the nurse should start assessing the patient for signs and symptoms of hypoglycemia closer to the time of peak action.
Choice D rationale
Assessing the patient for signs and symptoms of hypoglycemia at 1000, three hours after insulin administration, is within the peak action time of insulin aspart. Therefore, this is the most appropriate time to start assessing the patient for signs and symptoms of hypoglycemia.