Answers for A+ Grade Latest 2025
A nurse is teaching a client who has diabetes mellitus and a new prescription for a combination of lispro
insulin and NPH insulin. Which of the following statements by the client indicates an understanding of the
teaching?
Answer:
• "I will mix these medications in one syringe."
• "I should draw up the NPH insulin first."
Rationale:
• Lispro (a rapid-acting insulin) and NPH (an intermediate-acting insulin) can be mixed in the same
syringe to minimize injections.
• To prevent contamination, the clear insulin (lispro) should be drawn up first, followed by
the cloudy insulin (NPH).
• Lispro insulin is clear, not cloudy, and it begins working quickly, so the client should eat within 15
minutes of administration, not 1 hour
,A nurse is assessing an adult client who is receiving morphine via continuous IV infusion. The nurse should
identify that which of the following is the priority finding?
Answer:
Respirations deep at a rate of 10/min
Rationale:
When using the airway, breathing, circulation (ABC) priority framework, respiratory status is the highest
priority. Morphine is a respiratory depressant. A respiratory rate of 10/min indicates respiratory depression,
which is a life-threatening adverse effect and requires immediate intervention. While the other findings
(hypotension, decreased urine output, vomiting) are concerning, they do not pose as immediate a threat to
survival as inadequate breathing.
,A nurse is preparing to administer amphotericin B lipid complex via intermittent IV bolus to a client who
has infective endocarditis. Which of the following actions should the nurse take?
Answer:
Administer the medication over 2 hr.
Rationale:
• Administer the medication over 2 hr: Amphotericin B lipid complex is typically infused over
approximately 2 hours to reduce the risk of infusion-related reactions. The exact time can vary by
specific product and facility protocol, but a prolonged infusion (not a rapid bolus) is standard.
• Discard the medication if it is yellow: This is incorrect. Amphotericin B lipid complex is a
translucent yellow suspension. A yellow color is normal and expected; the medication should not
be discarded for this reason.
• Use a gravity flow set: This is not recommended. An in-line filter is often required, and an IV pump
is typically used to control the infusion rate accurately and ensure patient safety
, A nurse is caring for a client who is at 32 weeks of gestation and has complete placenta previa. The client
experienced a sudden "gush" of bright red vaginal bleeding. Which of the following assessment findings
requires immediate follow-up?
Answer:
• Fetal heart rate
• Vaginal bleeding
Rationale:
In a client with placenta previa and active bleeding, the priority assessments are those that evaluate:
• Fetal well-being – A non-reassuring fetal heart rate can indicate fetal distress from hypoxia or
compromised blood flow, requiring immediate intervention.
• Maternal hemodynamic stability – Ongoing vaginal bleeding must be quantified and monitored
closely, as increased bleeding can lead to maternal shock and fetal compromise.