Question

A nurse is preparing to administer NPH insulin to a client Which of the following actions should the nurse take?

Answer 1

Correct Answers:

Gently roll the insulin vial between their hands to mix.

Rationale :

🔹 Ensures proper mixing of NPH insulin, which is a cloudy insulin, without creating bubbles that can affect dosage.

🔹 Maintains insulin potency by evenly distributing the suspension before administration.

🔹 Prevents inaccurate dosing which can occur if insulin is not properly mixed.

🔹 Avoids discomfort or tissue damage that can occur if insulin is injected unevenly or into the muscle.

🔹 Follows safe subcutaneous injection technique recommended for NPH insulin.

Hint:

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Answer 2

Correct Answers:

Establish a regular sleep pattern.

Rationale :

🟢 Promotes symptom management by reducing fatigue and improving overall energy.

🟢 Helps regulate pain perception since sleep disruption increases sensitivity to pain.

🟢 Supports mental health by decreasing anxiety and stress associated with fibromyalgia.

🟢 Improves immune function which can reduce symptom flare-ups.

🟢 Integrates into a comprehensive self-care routine including pacing activities and gentle exercise.

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Answer 3

Correct Answers:

“I will take gabapentin with a full glass of water and avoid taking it with antacids.”

Rationale :

⚫ Ensures proper absorption since antacids can reduce gabapentin bioavailability.

⚫ Prevents gastrointestinal irritation by taking with adequate water.

⚫ Maintains consistent therapeutic effect for neuropathic pain control.

⚫ Supports safe self-administration and prevents missed efficacy.

⚫ Encourages adherence to prescribed regimen which is crucial for chronic conditions.

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Answer 4

Correct Answers:

Ineffective Airway Clearance related to respiratory muscle weakness as evidence by a weak cough.

Rationale :

🔴 Addresses the most immediate threat to life—risk of airway obstruction or infection.

🔴 Recognizes compromised respiratory function due to muscle weakness in polymyositis.

🔴 Guides nursing interventions like suctioning, positioning, and pulmonary hygiene.

🔴 Prevents complications such as pneumonia or hypoxia.

🔴 Prioritizes patient safety over skin integrity or knowledge deficit, which are secondary concerns.

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Answer 5

Correct Answers:

Monitor vital signs before, during, and after phlebotomy and report any dizziness or hypotension to the RN.

Rationale :

🟣 Supports patient safety by ensuring hemodynamic status is monitored throughout the phlebotomy procedure.

🟣 Falls within PN scope of practice as it involves data collection and reporting rather than assessment or teaching.

🟣 Allows timely detection of hypotension or dizziness, which are common complications of phlebotomy in patients with elevated hematocrit.

🟣 Frees the RN to perform higher-level tasks such as patient education, assessment, and care planning.

🟣 Ensures collaboration and clear communication between RN and PN, which is critical for safe delegation in acute care settings.

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Answer 6

Correct Answers

Meperidine IV for pain [ Contraindicated ]
Ice packs to affected area 15 min on / 15 min off [ Anticipated ]
Oxygen 2 L/min via nasal cannula [ Nonessential ]
Ketorolac IV for pain [ Anticipated ]
Ambulate in hallway with supervision [ Nonessential ]
Intravenous fluids (IVF) at maintenance rate [ Anticipated ]

Rationale :

✅ Ice packs to affected area – Provides nonpharmacologic pain relief safely, reducing local discomfort without systemic effects.

✅ Ketorolac IV for pain – Adjunct NSAID therapy helps manage moderate pain alongside opioids if no contraindications exist.

✅ Intravenous fluids at maintenance – Hydration reduces sickling of RBCs and helps prevent vaso-occlusive complications.

✅ Oxygen 2 L/min – Not immediately necessary as SpO₂ is 97%, so supplemental oxygen is nonessential unless hypoxia develops.

✅ Meperidine IV – Contraindicated due to risk of neurotoxicity and seizures, especially in repeated dosing for sickle cell pain.

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Answer 7

Correct Answers:

Instruct the patient about proper handling and administration of methotrexate.
Educate the patient on maintaining proper posture to minimize spinal deformities.
Encourage regular physical exercise focusing on range of motion and strength training.
Administer NSAIDs as prescribed to reduce inflammation and pain.
Suggest a high-calcium diet to prevent osteoporosis associated with AS.

Rationale :

🔹 Instruct the patient about methotrexate – Ensures safe administration of disease-modifying antirheumatic drugs (DMARDs), reducing inflammation and disease progression.

🔹 Educate on maintaining proper posture – Prevents worsening kyphosis and spinal deformities, supporting spinal alignment.

🔹 Encourage regular physical exercise – Promotes range of motion and strength, reducing stiffness and preserving functional mobility.

🔹 Administer NSAIDs as prescribed – Reduces pain and inflammation, improving comfort and daily function.

🔹 Suggest high-calcium diet – Helps prevent osteoporosis, a common complication associated with chronic AS.

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Answer 8

Correct Answers:

200

Rationale :

🎀Dose: 5 mg IV bolus in 50 mL D5W over 15 min.

🎀Convert minutes to hours: 15 min = 0.25 hr.

🎀Flow rate formula: mL/hr = Total volume ÷ Time (hr)

🎀50 mL ÷ 0.25 hr = 200 mL/hr

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Answer 9

Correct Answers:

Encourage daily use of paraffin baths before performing hand exercises,

Rationale :

🟡 Reduces stiffness and pain in small joints, improving hand mobility.

🟡 Enhances circulation, allowing muscles and joints to warm before activity.

🟡 Supports functional independence by making hand exercises more effective.

🟡 Safe and low-risk intervention, suitable for patients with partial relief from medications.

🟡 Prepares joints for therapy, complementing pharmacologic management.

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Answer 10

Correct Answers:

"Unlike NHL, Hodgkin lymphoma typically spreads in an orderly, contiguous fashion through the lymphatic system."

Rationale :

🔹 Identifies hallmark pattern of spread: Hodgkin lymphoma spreads sequentially from one lymph node group to the next, unlike NHL, which can be scattered.

🔹 Reed-Sternberg cells confirm diagnosis and distinguish HL from NHL.

🔹 Helps predict clinical course and treatment planning due to its predictable progression.

🔹 Supports patient education on disease process and prognosis.

🔹 Guides monitoring and imaging as contiguous lymph node involvement is expected in HL.

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options	Anticipated	Nonessential	Contraindicated
Meperidine IV for pain
Ice packs to affected area 15 min on / 15 min off
Oxygen 2 L/min via nasal cannula
Ketorolac IV for pain
Ambulate in hallway with supervision
Intravenous fluids (IVF) at maintenance rate

Custom 2201 Unit 2 Exam 2025

No.

1 :
A nurse is preparing to administer NPH insulin to a client Which of the following actions should the nurse take?

2 :
A nurse is teaching a client who has fibromyalgia syndrome about measures to reduce the occurrence of symptoms? Which of the following interventions should the nurse include in the teaching?

3 :
A nurse is providing education to a client who has been prescribed gabapentin for diabetic neuropathy. Which of the following statements by the client indicates a correct understanding of the medication instructions?

6 :
A nurse is caring for a client with sickle cell pain, possibly leading into sickle cell crisis.

Correct Answers

7 :
A patient with ankylosing spondylitis (AS) presents with severe back pain, debilitating kyphosis, and decreased mobility. Which nursing interventions should be prioritized to manage this patient's symptoms and prevent further complications? (Select All that Apply.)

10 :
A 32-year-old patient presents with painless cervical lymphadenopathy. A biopsy confirms the presence of Reed-Sternberg cells. The nurse prepares teaching for the patient and family. Which statement best explains how Hodgkin lymphoma differs from non-Hodgkin lymphoma (NHL)?

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Custom 2201 Unit 2 Exam 2025

No.

1 : A nurse is preparing to administer NPH insulin to a client Which of the following actions should the nurse take?

2 : A nurse is teaching a client who has fibromyalgia syndrome about measures to reduce the occurrence of symptoms? Which of the following interventions should the nurse include in the teaching?

3 : A nurse is providing education to a client who has been prescribed gabapentin for diabetic neuropathy. Which of the following statements by the client indicates a correct understanding of the medication instructions?

6 : A nurse is caring for a client with sickle cell pain, possibly leading into sickle cell crisis.

Correct Answers

7 : A patient with ankylosing spondylitis (AS) presents with severe back pain, debilitating kyphosis, and decreased mobility. Which nursing interventions should be prioritized to manage this patient's symptoms and prevent further complications? (Select All that Apply.)

10 : A 32-year-old patient presents with painless cervical lymphadenopathy. A biopsy confirms the presence of Reed-Sternberg cells. The nurse prepares teaching for the patient and family. Which statement best explains how Hodgkin lymphoma differs from non-Hodgkin lymphoma (NHL)?

1 :
A nurse is preparing to administer NPH insulin to a client Which of the following actions should the nurse take?

2 :
A nurse is teaching a client who has fibromyalgia syndrome about measures to reduce the occurrence of symptoms? Which of the following interventions should the nurse include in the teaching?

3 :
A nurse is providing education to a client who has been prescribed gabapentin for diabetic neuropathy. Which of the following statements by the client indicates a correct understanding of the medication instructions?

6 :
A nurse is caring for a client with sickle cell pain, possibly leading into sickle cell crisis.

7 :
A patient with ankylosing spondylitis (AS) presents with severe back pain, debilitating kyphosis, and decreased mobility. Which nursing interventions should be prioritized to manage this patient's symptoms and prevent further complications? (Select All that Apply.)

10 :
A 32-year-old patient presents with painless cervical lymphadenopathy. A biopsy confirms the presence of Reed-Sternberg cells. The nurse prepares teaching for the patient and family. Which statement best explains how Hodgkin lymphoma differs from non-Hodgkin lymphoma (NHL)?