Question

A nurse is mixing a short-acting insulin and an intermediate- acting insulin in the same syringe for a client who has diabetes mellitus. Which following actions should the nurse take first?

Answer 1

Correct Answers:

Inject air into the intermediate-acting insulin vial-

Rationale :

💥When mixing insulins, the correct order prevents contamination of one insulin with another. 💥The nurse should first inject air into the intermediate-acting (cloudy) insulin vial without withdrawing medication. 💥This maintains the sterility and concentration of the short-acting (clear) insulin, which must remain uncontaminated.

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Answer 2

Correct Answers:

Notify the provider

Rationale :

✅If the client expresses a lack of understanding about a surgical procedure, the nurse must notify the provider. ✅The provider holds the legal and ethical responsibility to ensure the client is fully informed and consents knowingly. ✅The nurse’s role is to witness the signature and assess comprehension—not to explain the procedure.

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Answer 3

Correct Answers:

Assault

Rationale :

💥Threatening to apply restraints without consent constitutes assault, which is defined as an intentional act that causes the client to fear harmful or offensive contact. 💥The AP’s statement creates a threatening environment, violating the client’s rights and autonomy.

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Answer 4

Correct Answers:

"You will need to wear a mask when outside of your room."

Rationale :

✅Clients receiving allogeneic stem cell transplants are at high risk for infection due to immunosuppression. ✅ Wearing a mask when outside of their protective room reduces exposure to airborne pathogens. ✅This action supports reverse isolation protocols to protect the immunocompromised client.

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Answer 5

Correct Answers:

Peripheral pulses

Rationale :

💥When a client is in restraints, circulation to the restrained extremities must be evaluated first to ensure perfusion is not compromised. 💥 Peripheral pulse checks help detect early signs of vascular restriction such as pallor, coolness, or decreased capillary refill—preventing complications like nerve damage or ischemia.

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Answer 6

Correct Answers:

Dilated pupils

Rationale :

💥During the alarm stage of the general adaptation syndrome (GAS), the sympathetic nervous system activates the “fight-or-flight” response. 💥This includes pupil dilation to enhance vision and alertness. 💥It is a primary physiologic response to acute stress and part of the body’s survival mechanism.

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Answer 7

Correct Answers:

The client's belief that his needs will be met through education

Rationale :

💥According to principles of adult learning (Knowles’ Adult Learning Theory), intrinsic motivation and personal relevance are critical to client engagement. 💥Adults are more likely to learn when they perceive that the information will help them solve a real-life problem or meet a need. 💥In this case, the client’s belief that education will help manage his condition increases his willingness to learn and apply new skills, such as administering low-dose heparin. 💥This belief fosters self-efficacy and autonomy—essential for long-term health behavior change.

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Answer 8

Correct Answers:

The scale measures six elements

Rationale :

✅The Braden Scale is an evidence-based tool used to assess a client’s risk for developing pressure injuries. ✅It evaluates six specific criteria: sensory perception, moisture, activity, mobility, nutrition, and friction/shear. ✅Each element is scored based on risk severity, and the total score guides nursing interventions. ✅A lower total score indicates higher risk. ✅Recognizing the scale’s components allows nurses to prioritize skin care and implement targeted preventative strategies such as repositioning schedules and moisture control.

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Answer 9

Correct Answers:

Review the use of an artificial larynx with the client

Rationale :

💥A total laryngectomy results in permanent loss of natural voice, as the vocal cords are removed. 💥The priority nursing action preoperatively is to introduce and educate the client about alternative communication methods, such as an artificial larynx. 💥This not only facilitates early psychological adjustment but also ensures that the client will be able to express needs and participate in care postoperatively. 💥Communication support is essential for reducing anxiety and improving outcomes.

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Answer 10

Correct Answers:

Assist the client with a bowel cleansing

Rationale :

💥An intravenous pyelogram (IVP) uses contrast dye and radiographic imaging to visualize the kidneys, ureters, and bladder. 💥Fecal content in the intestines can obstruct clear visualization of the urinary tract. 💥Therefore, bowel cleansing is essential to ensure diagnostic accuracy. The nurse must prepare the client by administering prescribed laxatives or enemas and confirming the bowel is adequately cleared before the procedure. 💥This step is a standard pre-procedural requirement to ensure high-quality imaging.

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RN Fundamentals 2019

No.

1 : A nurse is mixing a short-acting insulin and an intermediate- acting insulin in the same syringe for a client who has diabetes mellitus. Which following actions should the nurse take first?

2 : A nurse is caring for a client who is scheduled for surgery. While the nurse is witnessing the client's signature, the client states, "l trust my doctor, but I don't understand what is meant by resecting my intestines." Which of the following actions should the nurse take?

4 : A nurse is providing teaching for a client who is scheduled for an allogeneic stem cell transplant. Which of the following information should the nurse include?

5 : A nurse is caring for a client who has restraints to each extremity. Which of the following assessments should the nurse perform first?

6 : A nurse is discussing the stages of general adaptation syndrome with a newly licensed nurse. The nurse should identify that which of the following manifestations occurs during the alarm reaction stage?

7 : A nurse is teaching a client how to self-administer daily low-dose heparin injections. Which of the following factors is most likely to increase the client's motivation to learn?

8 : A nurse is teaching a group of newly licensed nurses about the Braden scale. Which of the following responses by a newly licensed nurse indicates an understanding of the teaching?

9 : A nurse is providing care for a client who is to undergo a total laryngectomy. Which of the following interventions is the nurse's priority?

10 : A nurse is planning care for a client who is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

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