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 :

💎NPH insulin (an intermediate-acting insulin) is a suspension, meaning it contains particles that settle when standing.

💎To ensure even distribution, the vial should be gently rolled between the palms to mix—never shaken, as this creates air bubbles and alters dose accuracy.

💎The insulin is administered subcutaneously, not intramuscularly, to allow for slower absorption consistent with its duration of action.

💎It should be injected into subcutaneous tissue (e.g., abdomen, thigh, or upper arm), maintaining proper site rotation to prevent lipohypertrophy.

💎Aspirating before injection is not recommended, as it increases discomfort and risk of tissue trauma.

💎Proper vial preparation ensures accurate dosing, consistent absorption, and effective glycemic control.

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Answer 2

Correct Answers:

Establish a regular sleep pattern.

Rationale :

🔷Fibromyalgia is a chronic pain disorder characterized by widespread musculoskeletal pain, fatigue, and sleep disturbances due to altered pain perception.

🔷Establishing a consistent sleep routine enhances restorative rest, reduces fatigue, and helps minimize pain flare-ups.

🔷Clients should maintain a balanced exercise routine such as low-impact activities (swimming, walking, stretching) rather than high-impact exercises like jogging, which can worsen symptoms.

🔷Adequate sleep and stress reduction are key nonpharmacologic interventions for symptom control.

🔷Sleep hygiene includes maintaining a dark, quiet environment, avoiding caffeine before bedtime, and following a consistent sleep–wake schedule.

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Answer 3

Correct Highlights :

Limit sitting with legs crossed.
Anticipate an order for therapeutic phlebotomy.
Instruct client to bathe with cool water.

Rationale :

Hematologic System

Limit sitting with legs crossed.

💎Crossing the legs restricts venous return, further impairing circulation in a client already prone to hyperviscosity and thrombosis.

The nurse should encourage frequent movement, leg elevation, and adequate hydration to decrease clotting risk.

💎Low-dose aspirin (if prescribed) helps reduce platelet aggregation, but high-dose therapy increases bleeding risk and should not be initiated without provider order.

💎These measures enhance blood flow and reduce vascular complications associated with PV.

Cardiovascular System

Anticipate an order for therapeutic phlebotomy.

💎Therapeutic phlebotomy is the main treatment for polycythemia vera — it removes blood at regular intervals to lower hematocrit to below 45%, reducing viscosity and cardiac workload.

💎Lowering RBC mass decreases blood pressure, clot formation, and risk of cardiovascular events.

💎The nurse should also maintain oxygen saturation >95% to prevent tissue hypoxia, which could stimulate further erythropoietin release.

💎Regular monitoring of vitals, fluid status, and hematocrit helps evaluate treatment effectiveness.

💎Phlebotomy combined with hydration minimizes hypervolemia and hypertension complications.

Integumentary System

Instruct client to bathe with cool water.

💎Clients with PV often develop aquagenic pruritus, a histamine-mediated itching that worsens with warm water exposure.

💎Bathing in cool or tepid water constricts skin vessels, reducing histamine release and minimizing discomfort.

💎The nurse can also recommend patting skin dry (not rubbing), using soothing lotions, and avoiding hot showers.

💎Topical steroids or antihistamines may be prescribed for additional relief, but environmental control (cool baths) is the first-line nonpharmacologic intervention.

💎Comfort promotion helps prevent scratching-related skin breakdown or infection.

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Answer 4

Correct Answers:

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

Rationale :

💎Gabapentin is an anticonvulsant and neuropathic pain agent often prescribed for diabetic neuropathy.

💎It should be taken with plenty of water to aid absorption and should not be taken with antacids, as antacids reduce the medication’s bioavailability by interfering with gastrointestinal absorption.

💎Clients should be instructed to take missed doses as soon as remembered, but never double doses or take them too close together.

💎Abrupt discontinuation can cause withdrawal symptoms or seizure activity, so tapering under medical supervision is necessary.

💎The nurse should also teach the client to report mood changes, suicidal thoughts, or unusual feelings immediately, as gabapentin can affect mental status.

💎Safe medication practices help prevent toxicity, poor absorption, and withdrawal complications.

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Answer 5

Correct Answers:

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

Rationale :

🔷The patient with polymyositis, an inflammatory muscle disease, exhibits dysphagia, decreased breath sounds, weak cough, and sputum production, which indicate respiratory muscle involvement.

🔷These findings suggest ineffective airway clearance, the most life-threatening problem and thus the priority diagnosis.

🔷Impaired ability to clear secretions increases the risk for hypoxia, atelectasis, and respiratory infection.

🔷The nurse should focus on airway management, including cough assistance, incentive spirometry, chest physiotherapy, and suctioning if needed.

🔷While knowledge deficit, skin integrity, and chronic pain are important, airway and oxygenation take priority based on the ABC framework (Airway, Breathing, Circulation).

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Answer 6

Correct Answers:

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

Rationale :

🟢The practical nurse (PN) can safely perform routine monitoring of vital signs and report abnormalities to the RN during procedures like therapeutic phlebotomy.

🟢Clients with polycythemia vera undergoing phlebotomy are at risk for hypotension, dizziness, and fainting due to volume loss.

🟢The RN maintains accountability for assessment, education, and care planning, but the PN can collect objective data and recognize/report concerning changes.

🟢Tasks involving education, assessment, or developing individualized care plans require RN-level critical judgment and cannot be delegated.

🟢This delegation ensures safe monitoring while allowing the RN to focus on complex interventions and decision-making.

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Answer 7

Correct Answers

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

Rationale :

Oxygen 2 L/min via nasal cannula — Anticipated

🔷 Even with an SpO₂ of 97%, vaso-occlusion can cause micro-regional tissue hypoxia not always reflected on pulse oximetry; a low-flow NC can help optimize oxygen delivery while pain and crisis are being stabilized.

🔷 Sickle hemoglobin (HbS) polymerizes under low O₂ tension, so maintaining ≥95% saturation helps limit further sickling and ischemic pain.

🔷 Oxygen is a low-risk supportive therapy while the team evaluates for evolving complications (e.g., acute chest syndrome), especially if pain escalates or sedation from opioids could depress ventilation.

🔷 Combine oxygen with continuous pulse-ox, consider ABG if concerns for hypoventilation or occult hypoxemia, and titrate to the lowest flow that keeps targets met.

🔷 Reassess frequently; once stable and clearly not hypoxic, oxygen can be weaned to avoid unnecessary use.

Intravenous fluids at maintenance rate — Anticipated

🔷 Vaso-occlusive crises often involve hemoconcentration and increased viscosity; gentle isotonic IV hydration (e.g., 0.9% saline at maintenance rate) can improve microcirculatory flow.

🔷 Adequate hydration helps separate sickled erythrocytes, reducing microvascular plugging and supporting tissue perfusion.

🔷 Avoid over-hydration, which can precipitate pulmonary edema or worsen acute chest syndrome—use weight-based rates and adjust for renal function.

🔷 Monitor I&O, urine output (goal ≥ 0.5 mL/kg/hr), electrolytes, and clinical signs of volume status.

🔷 Combine with early, appropriate analgesia, because pain-related catecholamine surge exacerbates vasoconstriction.

Ketorolac IV for pain — Nonessential

🔷NSAIDs like ketorolac can decrease prostaglandin-mediated pain and serve as opioid-sparing adjuncts, but they are not first-line for severe vaso-occlusive pain.

🔷Use is time-limited (≤5 days) due to risks of renal injury, GI bleeding, and platelet inhibition—important in SCD where renal vulnerability is higher.

🔷Consider only in addition to scheduled opioids and when renal function is adequate (e.g., normal creatinine, euvolemia).

🔷Assess for contraindications (active bleeding, peptic ulcer disease, AKI, dehydration).

🔷If used, pair with gastroprotection as indicated and ongoing renal monitoring.

Ambulate in hallway with supervision — Contraindicated

🔷During an acute vaso-occlusive episode, uncontrolled pain and micro-ischemia mean ambulation can increase oxygen demand and worsen ischemia and pain.

🔷Early focus is rest, warmth, hydration, and analgesia until perfusion improves and pain is controlled.

🔷Premature exertion risks exacerbating crisis, falls due to pain, and syncope if hypotension develops after opioids or fluids.

🔷Gentle in-bed ROM and DVT prophylaxis (per protocol) are safer until clinically improved.

🔷Progress to ambulation after pain control and hemodynamic stabilization.

Ice packs to affected area 15 min on/15 min off — Contraindicated

🔷 Cold causes vasoconstriction, which reduces blood flow in already compromised microcirculation, potentially worsening ischemia and pain.

🔷 Preferred local measure is gentle warmth (e.g., warm blankets, warm—not hot—compresses) to promote vasodilation and comfort.

🔷 Educate that “icing” sickle pain backfires by tightening vessels and aggravating vaso-occlusion.

🔷 Avoid excess heat that can burn insensate skin; use moderate warmth with frequent skin checks.

🔷 Pair local warmth with systemic hydration and opioids for maximal relief.

Meperidine IV for pain — Contraindicated

🔷 Meperidine (Demerol) is avoided due to its neurotoxic metabolite normeperidine, which accumulates (especially with repeated doses or renal impairment) and can cause CNS excitability and seizures.

🔷 Guideline-preferred opioids are morphine or hydromorphone, delivered IV and titrated to effect; consider PCA for steady control and fewer peaks/valleys.

🔷 Co-prescribe antiemetics and antipruritics PRN, and use multimodal analgesia (e.g., acetaminophen ± limited NSAID) when safe.

🔷 Frequent pain reassessment (e.g., q15–30 min during titration) ensures timely escalation if inadequate.

🔷 Reserve meperidine only for shivering control in specific peri-anesthesia contexts—not for SCD pain.

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Answer 8

Correct Answers:

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

Rationale :

Suggest a high-calcium diet to prevent osteoporosis associated with AS.

💎Ankylosing spondylitis (AS) is a chronic inflammatory disorder that affects the spine and sacroiliac joints, leading to stiffness, fusion, and postural deformities.

💎Long-term inflammation, limited mobility, and corticosteroid use can contribute to osteoporosis, increasing fracture risk.

💎A diet rich in calcium and vitamin D supports bone strength and reduces skeletal complications.

💎The nurse should encourage foods such as dairy, leafy greens, and fortified cereals, and collaborate for supplementation if dietary intake is inadequate.

💎Maintaining strong bone density helps stabilize posture and prevent compression fractures in the rigid spine.

Instruct the patient about proper handling and administration of methotrexate.

💎Methotrexate, a disease-modifying antirheumatic drug (DMARD), is sometimes used to manage systemic inflammation in AS, especially when peripheral joints are involved.

💎The nurse should provide education on weekly dosing, monitoring for hepatotoxicity, and the need for regular CBC and liver function tests.

💎Teach the patient to avoid alcohol, report signs of infection or mouth sores, and use folic acid supplementation to reduce adverse effects.

💎Correct administration ensures therapeutic effectiveness and prevents serious drug-related toxicity.

Educate the patient on maintaining proper posture to minimize spinal deformities.

💎AS causes spinal stiffness and progressive kyphosis, which can worsen without postural awareness and corrective exercises.

💎The nurse should emphasize upright posture, use of firm mattresses, and avoiding pillows under the head to prevent neck flexion contractures.

💎Posture training and ergonomic adjustments help slow deformity progression and improve balance and mobility.

💎Regular postural reinforcement prevents functional disability and respiratory compromise due to chest wall rigidity.

Administer NSAIDs as prescribed to reduce inflammation and pain.

💎NSAIDs (e.g., indomethacin, naproxen) are first-line therapy for AS, effectively reducing inflammation, stiffness, and pain.

💎These agents improve spinal mobility and quality of life by suppressing prostaglandin-mediated inflammatory responses.

💎The nurse should monitor for GI irritation, renal dysfunction, and cardiovascular risks during chronic use.

💎Consistent use helps maintain joint function and reduce morning stiffness, enhancing activity tolerance.

Encourage regular physical exercise focusing on range of motion and strength training.

💎Prolonged inactivity worsens stiffness and accelerates deformity in AS; thus, daily physical activity is critical.

💎Exercises such as swimming, stretching, deep breathing, and posture drills help maintain spinal flexibility and chest expansion.

💎The nurse should discourage bed rest and promote therapeutic exercise programs supervised by physical therapy.

💎Regular mobility practice helps preserve function, reduce pain, and delay ankylosis (spinal fusion).

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Answer 9

Correct Answers:

200

Rationale :

✍️Infusion rate

💎Volume ÷ Time.

💎Convert 15 min → 0.25 hr.

✍️Rate

💎50 mL ÷ 0.25 hr

200 mL/hr.

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Answer 10

Correct Answers:

Encourage daily use of paraffin baths before performing hand exercises.

Rationale :

💎For clients with rheumatoid arthritis (RA), heat therapy—such as paraffin wax baths or warm compresses—helps relieve morning stiffness, increase circulation, and loosen tight joints before exercise.

💎Applying heat relaxes muscles and improves flexibility, making hand exercises easier and more effective.

💎Cold therapy, by contrast, is used during acute inflammation to decrease swelling, not during chronic stiffness phases.

💎Clients should perform gentle range-of-motion exercises after warming the joints to prevent contractures and maintain mobility.

💎Consistent use of heat therapy is a key non-pharmacologic pain management strategy in RA.

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

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 in an emergency department (ED) is caring for a male client.

Correct Highlights :

4 :
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?

7 :
A nurse is caring for a client with sickle cell pain, possibly leading into sickle cell crisis.

Correct Answers

8 :
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)

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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 in an emergency department (ED) is caring for a male client.

Correct Highlights :

4 : 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?

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

Correct Answers

8 : 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)

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 in an emergency department (ED) is caring for a male client.

4 :
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?

7 :
A nurse is caring for a client with sickle cell pain, possibly leading into sickle cell crisis.

8 :
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)