Adult Health Prep U chapter 10, 26, 27, 46
Light-headedness or paresthesia
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Headache or blurry vision Abdominal pain or diarrhea Hallucinations or tinnitus Light-headedness or paresthesia
No, sodium intake should be restricted.
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? Yes, this will correct the sodium deficit. Yes, along with the hypotonic IV. No, start with the sodium chloride IV. No, sodium intake should be restricted.
Active transport
A client with hypervolemia asks the nurse by what mechanism the sodium-potassium pump will move the excess body fluid. What is the nurse's best answer? Passive osmosis Free flow Passive elimination Active transport
Computed tomography angiography (CTA)
A health care provider wants a cross-sectional image of the abdomen to evaluate the degree of stenosis in a patient's left common iliac artery. The nurse knows to prepare the patient for which of the following? Doppler ultrasound Magnetic resonance angiography (MRA) Angiography Computed tomography angiography (CTA)
Ketosis-prone Little or no endogenous insulin younger than 30 years of age
A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply. Ketosis-prone Little or no endogenous insulin Obesity at diagnoses Younger than 30 years of age Older than 65 years of age
Rebound hypertension
A patient is flying overseas for 1 week for business and packed antihypertensive medications in a suitcase. After arriving at the intended destination, the patient found that the luggage had been stolen. If the patient cannot take the medication, what condition becomes a concern? Isolated systolic hypertension Rebound hypertension Angina Left ventricular hypertrophy
130 mEq/L (130 mmol/L) ( convulsions or coma can occur if the deficit is severe. Values of 140, 142, and 145 mEq/L (mmol/L) are within the normal range.) (Normal serum concentration level ranges from 135 to 145 mEq/L (135-145 mmol/L).)
At which serum sodium concentration might convulsions or coma occur? 130 mEq/L (130 mmol/L) 145 mEq/L (145 mmol/L) 140 mEq/L (140 mmol/L) 142 mEq/L (142 mmol/L)
Cigarette smoking.
Health teaching includes advising patients on ways to reduce PAD. The nurse should always emphasize that the strongest risk factor for the development of atherosclerotic lesions is: Cigarette smoking. Lack of exercise. Obesity. Stress.
secondary hypertension.
Hypertension that can be attributed to an underlying cause is termed primary hypertension. essential hypertension. secondary hypertension. isolated systolic hypertension.
increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood.
It is appropriate for the nurse to recommend smoking cessation for clients with hypertension because nicotine? increases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. decreases the heart rate, constricts arterioles, and reduces the heart's ability to eject blood. increases the heart rate, constricts arterioles, and increases the heart's ability to eject blood. decreases circulating blood volume.
Serum glycosylated hemoglobin (Hb A1c)
Laboratory studies indicate a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use? Fasting blood glucose test 6-hour glucose tolerance test Serum glycosylated hemoglobin (Hb A1c) Urine ketones
Rapid-acting
Lispro (Humalog) is an example of which type of insulin? Rapid-acting Intermediate-acting Short-acting Long-acting
decreases the production of neurotransmitters that constrict peripheral arterioles.
Nurses should implement measures to relieve emotional stress for clients with hypertension because the reduction of stress?? increases the production of neurotransmitters that constrict peripheral arterioles. increases the resistance that the heart must overcome to eject blood. increases blood volume and improves the potential for greater cardiac output. decreases the production of neurotransmitters that constrict peripheral arterioles.
A ripping sensation in the chest
The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta? Numbness and pain of the left arm Pain when flexing the neck forward Gradual onset of a frontal headache A ripping sensation in the chest
Hypothalamus
Oral intake is controlled by the thirst center, located in which of the following cerebral areas? Hypothalamus Cerebellum Brainstem Thalamus
ophthalmic examination. ( Papilledema is an edema of the optic nerves, and thus needs an ophthalmic examination for detection.)
Papilledema is a fairly common symptom of elevated blood pressure. The best way to detect this condition is through: ophthalmic examination. using a sphygmomanometer. laboratory tests. an MRI.
Claudication
Pentoxifylline (Trental) is a medication used for which of the following conditions? Claudication Thromboemboli Hypertension Elevated triglycerides
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L
The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L pH: 7.40, PaCO2: 40 mm Hg, HCO3-: 24 mEq /L
decreases venous congestion.
The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: reduces stress. aids in weight reduction. increases high-density lipoprotein (HDL) level. decreases venous congestion.
regular
The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously? NPH Regular Lispro Lantus
Anterior surface of the foot near the ankle joint
To assess the dorsalis pedis artery, the nurse would use the tips of three fingers and apply light pressure to the: Inside of the ankle just above the heel. Exterior surface of the foot near the heel. Outside of the foot just below the heel. Anterior surface of the foot near the ankle joint.
pH PaCO2 HCO3
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. pH PaCO2 HCO3 Glucose Na+ K+
4 to 6 hours
What is the duration of regular insulin? 4 to 6 hours 3 to 5 hours 12 to 16 hours 24 hours
insulin resistance
Which is a characteristic of type 2 diabetes? insulin resistance presence of islet antibodies little or no insulin ketosis-prone when insulin absent
hypotonic
half-normal saline solution is what ?
Lungs and kidney
the nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? Kidney and liver Heart and lungs Lungs and kidney Pancreas and stomach
hypertonic
what is 5% dextrose and normal saline solution (with an osmolality of 559 mOsm/L) or 10% dextrose in water (with an osmolality of 505 mOsm/L) .
Atherosclerosis
You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? Aneurysm Coronary thrombosis Atherosclerosis Raynaud's disease
hypertension diabetes obesity family history of early cardiovascular events
What risk factors would cause the nurse to become concerned that the client may have atherosclerotic heart disease? Select all that apply. hypertension diabetes obesity lowered triglyceride levels active lifestyle family history of early cardiovascular events
Furosemide
A client with lower extremity edema is diagnosed with lymphedema. For which medication will the nurse prepare teaching for this client? Oxycodone Furosemide Amoxicillin Heparin
"Your child will need less blood work as his glucose levels stabilize."
A physician orders blood glucose levels every 4 hours for a 4-year-old child with brittle type 1 diabetes. The parents are worried that drawing so much blood will traumatize their child. How can the nurse best reassure the parents? "Your child will need less blood work as his glucose levels stabilize." "Your child is young and will soon forget this experience." "I'll see if the physician can reduce the number of blood draws." "Our laboratory technicians use tiny needles and they're really good with children."
Protamine sulfate
A postoperative client is receiving heparin after developing thrombophlebitis. The nurse monitors the client carefully for bleeding and other adverse effects of heparin. If the client starts to exhibit signs of excessive bleeding, the nurse should expect to administer an antidote that is specific to heparin. Which agent fits this description? Phytonadione (vitamin K) Protamine sulfate Thrombin Plasma protein fraction
Dehydration
The nurse is caring for an older adult client in the home setting who is experiencing decreased thirst. Which type of fluid imbalance should the nurse anticipate? Dehydration Hypovolemia Hypervolemia Third spacing
decreases venous congestion
The most important reason for a nurse to encourage a client with peripheral vascular disease to initiate a walking program is that this form of exercise: reduces stress. aids in weight reduction. increases high-density lipoprotein (HDL) level. decreases venous congestion.
Diminished or absent pulses
The nurse assessing a client who has arterial insufficiency of the legs and an ulcer on the left great toe would expect to find which characteristic? Diminished or absent pulses Superficial ulcer Aching, cramping pain Pulses that are present but difficult to palpate
Loss of arterial elasticity
The nurse is caring for an older adult client who has come to the clinic for a yearly physical. When assessing the client, the nurse notes the blood pressure (BP) is 140/93. The nurse knows that in older clients what happens that may elevate the systolic BP? Loss of arterial elasticity Decrease in blood volume Increase in calcium intake Decrease in cardiac output
Instruct the client to breathe into a paper bag.
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? Administer an ordered decongestant. Instruct the client to breathe into a paper bag. Offer the client fluids frequently. Administer ordered supplemental oxygen.
Alcoholism
Which is the most common cause of symptomatic hypomagnesemia? Intravenous drug use Alcoholism Sedentary lifestyle Burns
Sodium bicarbonate
Which medication does the nurse anticipate administering to antagonize the effects of potassium on the heart for a patient in severe metabolic acidosis? Sodium bicarbonate Magnesium sulfate Furosemide Calcium gluconate
sodium ( Sodium plays a major role in controlling water distribution throughout the body because it does not easily cross the intracellular wall membrane and because of its abundance and high concentration in the body.)
Which of the following electrolytes is the primary determinant of extracellular fluid (ECF) osmolality? Sodium Potassium Calcium Magnesium
The client has eaten and has not taken or received insulin.
Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes? The client continues medication therapy despite adequate food intake. The client has not consumed sufficient calories. The client has been exercising more than usual. The client has eaten and has not taken or received insulin.
Elevated blood urea nitrogen (BUN) and creatinine Rapid onset More common in type 1 diabetes
Which of the following is a characteristic of diabetic ketoacidosis (DKA)? Select all that apply. Elevated blood urea nitrogen (BUN) and creatinine Rapid onset More common in type 1 diabetes Absent ketones Normal arterial pH level
systolic pressure below 150 mm Hg. ( Currently, it is believed that in persons younger than 60 years of age, reducing the systolic pressure below 140 mm Hg is more important than decreasing the diastolic blood pressure. In persons older than 60 years, the goal is below 150 mm Hg.)
A 65-year-old client is beginning medical management of recently diagnosed hypertension. The most important strategy in this client's treatment is reducing: systolic pressure below 150 mm Hg. systolic pressure below 130 mm Hg. diastolic pressure below 90 mm Hg. diastolic pressure below 80 mm Hg.
Participate in a regular walking program.
A client has been diagnosed with peripheral arterial occlusive disease. Which of the following instructions is appropriate for the nurse to give the client for promoting circulation to the extremities? Keep the extremities elevated slightly. Participate in a regular walking program. Use a heating pad to promote warmth. Massage the calf muscles if pain occurs.
Numbness and weakness in the left arm ( Hypertensive emergencies are acute, life-threatening BP elevations that require prompt treatment in an intensive care setting because of the serious target organ damage that may occur. The finding of numbness and weakness in left arm may indicate the client is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP; immediate intervention is required.)
A client is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The client's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV nitroprusside. Upon assessment, which finding requires immediate intervention by the nurse? Numbness and weakness in the left arm Nausea and severe headache Chest pain score of 3 (on a scale of 1 to 10) Urine output of 40 mL over the past hour
Essential (primary) (Essential or primary hypertension, about 95% of cases, is sustained elevated BP with no known cause. This client does not have secondary, pathologic, or malignant hypertension.)
A client is being seen at the clinic for a routine physical when the nurse notes the client's blood pressure is 150/97. The client is considered to be a healthy, well-nourished young adult. What type of hypertension does this client have? Secondary Pathologic Malignant Essential (primary)
Reduce the blood pressure by 20% to 25% within the first hour of treatment.
A client is brought to the emergency department with reports of a bad headache and an increase in blood pressure. The blood pressure reading obtained by the nurse is 260/180 mm Hg. What is the therapeutic goal for reduction of the mean blood pressure? Reduce the blood pressure by 20% to 25% within the first hour of treatment. Reduce the blood pressure to about 140/80 mm Hg. Rapidly reduce the blood pressure so the client will not suffer a stroke. Reduce the blood pressure by 50% within the first hour of treatment
Reduce the blood pressure by 20% to 25% within the first hour of treatment.
A client is brought to the emergency department with reports of a bad headache and an increase in blood pressure. The blood pressure reading obtained by the nurse is 260/180 mm Hg. What is the therapeutic goal for reduction of the mean blood pressure? Reduce the blood pressure by 20% to 25% within the first hour of treatment. Reduce the blood pressure to about 140/80 mm Hg. Rapidly reduce the blood pressure so the client will not suffer a stroke. Reduce the blood pressure by 50% within the first hour of treatment.
"I chose broiled chicken with a baked potato for dinner."
A client is placed on a low-sodium (500 mg/day) diet. Which client statement indicates that the nurse's nutrition teaching plan has been effective? "I can still eat a ham-and-cheese sandwich with potato chips for lunch." "I chose broiled chicken with a baked potato for dinner." "I chose a tossed salad with sardines and oil and vinegar dressing for lunch." "I'm glad I can still have chicken bouillon."
7:45 AM
A client is receiving insulin lispro at 7:30 AM. The nurse ensures that the client has breakfast by which time? 7:45 AM 8:00 AM 8:15 AM 8:30 AM
Hyperkalemia
A client is taking 50 mg of oral spironolactone twice a day to assist with blood pressure control. While the nurse is performing the morning assessment, the client reports nausea, general muscle cramps, and weakness. The ECG strip shows a peaked, narrow T-wave, which is a change. What electrolyte imbalance does the nurse suspect? Hyperkalemia Hypokalemia Hypernatremia Hyponatremia
Potassium level
A client is taking amiloride and lisinopril for the treatment of hypertension. What laboratory studies should the nurse monitor while the client is taking these two medications together? Magnesium level Potassium level Calcium level Sodium level
Potassium level ( Amiloride (Midamor) is a potassium-sparing diuretic, meaning that it causes potassium retention. The nurse should monitor for hyperkalemia (elevated potassium level) if given with an ACE inhibitor, such as lisinopril (Zestril) or angiotensin receptor blocker.)
A client is taking amiloride and lisinopril for the treatment of hypertension. What laboratory studies should the nurse monitor while the client is taking these two medications together? Magnesium level Potassium level Calcium level Sodium level
Rapid, thready pulse
A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level? Cool, moist skin Rapid, thready pulse Arm and leg trembling Slow, shallow respirations
Serum osmolarity
A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide. Which laboratory test is the most important for confirming this disorder? Serum potassium level Serum sodium level Arterial blood gas (ABG) values Serum osmolarity
Deficient knowledge (treatment regimen). ( the client should inject insulin before, not after, breakfast and dinner — 30 minutes before breakfast for the a.m. dose and 30 minutes before dinner for the p.m. dose. Therefore, the client has a knowledge deficit regarding when to administer insulin. By taking insulin, measuring blood glucose levels, and seeing the physician regularly, the client has demonstrated the ability and willingness to modify his lifestyle as needed to manage the disease. This behavior eliminates the nursing diagnoses of Impaired adjustment and Defensive coping. Because the nurse, not the client, questioned the client's health practices related to diabetes management, the nursing diagnosis of Health-seeking behaviors isn't warranted.)
A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of: Impaired adjustment. Defensive coping. Deficient knowledge (treatment regimen). Health-seeking behaviors (diabetes control).
Raynaud's disease
A client with systemic lupus erythematosus (SLE) complains that his hands become pale, blue, and painful when exposed to the cold. What disease should the nurse cite as an explanation for these signs and symptoms? Peripheral vascular disease Raynaud's disease Arterial occlusive diseases Buerger's disease
Hypokalemia and hypoglycemia
A client with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestation(s) associated with this classic symptom? Weight gain Muscle wasting and tissue loss Dehydration Altered mental state
Muscle wasting and tissue loss
A client with type 1 diabetes is experiencing polyphagia. The nurse knows to assess for which additional clinical manifestation(s) associated with this classic symptom? Weight gain Muscle wasting and tissue loss Dehydration Altered mental state
Secondary
A client, newly admitted to the nursing unit, has a primary diagnosis of renal failure. When assessing the client, the nurse notes a blood pressure (BP) of 180/100. The nurse knows that this is what kind of hypertension? Primary Essential Secondary Malignant
The client can walk about 50 feet before getting pain in the right lower leg. ( Intermittent claudication is caused by the inability of the arterial system to provide adequate blood flow to the tissues when increased demands are made for oxygen and nutrients during exercise. Pain is then experienced. When the client rests and decreases demands, the pain subsides. The client can then walk the same distance and repeat the process.)
A nurse and physician are preparing to visit a hospitalized client with peripheral arterial disease. As you approach the client's room, the physician asks if the client has reported any intermittent claudication. The client has reported this symptom. The nurse explains to the physician which of the following details? The client can walk about 50 feet before getting pain in the right lower leg. The client's fingers tingle when left in one position for too long. The client experiences shortness of breath after walking about 50 feet. The client's legs awaken him during the night with itching.
Increased urine output
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia? Cheyne-Stokes respirations Increased urine output Decreased appetite Diaphoresis
Albumin
A nurse is caring for a diabetic patient with a diagnosis of nephropathy. What would the nurse expect the urinalysis report to indicate? Albumin Bacteria Red blood cells White blood cells
Sit quietly for 5 minutes prior to taking blood pressure." ( nstructions for the client regarding measuring the blood pressure at home include the following: (1) Avoid smoking cigarettes or drinking caffeine for 30 minutes before measuring blood pressure. (2) Sit quietly for 5 minutes before the measurement. (3) Have the forearm supported at heart level, with both feet on the ground during the measurement of the blood pressure.)
A nurse is educating a client about monitoring blood pressure readings at home. What will the nurse be sure to emphasize? "Avoid smoking cigarettes for 8 hours prior to taking blood pressure." "Sit quietly for 5 minutes prior to taking blood pressure." "Sit with legs crossed when taking your blood pressure." "Be sure the forearm is well supported above heart level while taking blood pressure."
It takes 2 to 3 months for the taste buds to adapt to decreased salt intake.
A nurse is educating about lifestyle modifications for a group of clients with newly diagnosed hypertension. While discussing dietary changes, which point would the nurse emphasize? It takes 2 to 3 months for the taste buds to adapt to decreased salt intake. The taste buds never adapt to decreased salt intake. There is usually no need to change alcohol consumption for clients with hypertension. A person with hypertension should never consume alcohol.
forcing blood into the deep venous system. ( Antiembolism stockings prevent DVT by forcing blood into the deep venous system, instead of allowing blood to pool.)
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: encouraging ambulation to prevent pooling of blood. providing warmth to the extremity. elevating the extremity to prevent pooling of blood. forcing blood into the deep venous system.
100 units of regular insulin in normal saline solution
A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy? 100 units of regular insulin in normal saline solution 100 units of neutral protamine Hagedorn (NPH) insulin in normal saline solution 100 units of regular insulin in dextrose 5% in water 100 units of NPH insulin in dextrose 5% in water
The short-acting insulin is withdrawn before the intermediate-acting insulin. ( When combining two types of insulin in the same syringe, the short-acting regular insulin is withdrawn into the syringe first and the intermediate-acting insulin is added next. This practice is referred to as "clear to cloudy.")
A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication? The short-acting insulin is withdrawn before the intermediate-acting insulin. The intermediate-acting insulin is withdrawn before the short-acting insulin. Different types of insulin are not to be mixed in the same syringe. If administered immediately, there is no requirement for withdrawing one type of insulin before another.
Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy."
A nurse is teaching a client recovering from diabetic ketoacidosis (DKA) about management of "sick days." The client asks the nurse why it is important to monitor the urine for ketones. Which statement is the nurse's best response? "Ketones are formed when insufficient insulin leads to cellular starvation. As cells rupture, they release these acids into the blood." "When the body does not have enough insulin, hyperglycemia occurs. Excess glucose is broken down by the liver, causing acidic by-products to be released." "Excess glucose in the blood is metabolized by the liver and turned into ketones, which are an acid." "Ketones accumulate in the blood and urine when fat breaks down in the absence of insulin. Ketones signal an insulin deficiency that will cause the body to start breaking down stored fat for energy."
130/80 or lower ( The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7) specifies a lower goal pressure of 130/80 for people with diabetes mellitus.)
A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. What will the nurse specify about this client's target blood pressure? 145/95 or lower 130/80 or lower 150/95 or lower 125/85 or lower
"Rebound hypertension can occur."
A nurse is teaching a client with newly diagnosed hypertension who asks if there is any harm in stopping antihypertensive medication. What is the nurse's best response? "Rebound hypertension can occur." "Postural hypotension can occur." "Rebound hypotension can occur." "Postural hypertension can occur."
Smoking Diabetes mellitus Physical inactivity
A nurse providing education about hypertension to a community group is discussing the high risk for cardiovascular complications. What are risk factors for cardiovascular problems in clients with hypertension? Select all that apply. Gallbladder disease Smoking Diabetes mellitus Physical inactivity Frequent upper respiratory infections
Echocardiography
A patient with long-standing hypertension is admitted to the hospital with hypertensive urgency. The physician orders a chest x-ray, which reveals an enlarged heart. What diagnostic test does the nurse anticipate preparing the patient for to determine left ventricular enlargement? Cardiac catheterization Echocardiography Stress test Tilt-table test
Demonstrate how to apply and remove elastic support stockings.
As the clinic nurse caring for a client with varicose veins, what is an appropriate nursing action for this client? Demonstrate how to self-administer IV infusions. Demonstrate how to apply and remove elastic support stockings. Assess for the sites of bleeding. Assess for skin integrity.
10 to 15 g of a simple carbohydrate.
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting: 2 to 5 g of a simple carbohydrate. 10 to 15 g of a simple carbohydrate. 18 to 20 g of a simple carbohydrate. 25 to 30 g of a simple carbohydrate.
Change positions (lying or sitting to standing) slowly.
An older adult client has newly diagnosed stage 2 hypertension. The health care provider has prescribed the client hydrochlorothiazide and enalapril. What will the nurse be sure to include in educating this client? Change positions (lying or sitting to standing) slowly. Check blood pressure every day for signs of rebound hypertension. Do not become dependent on canes, walkers, or handrails. Eat plenty of salty food to prevent hypotension.
1.5 to 2.5
Heparin therapy is usually considered therapeutic when the activated partial thromboplastin time (aPTT) is how many times higher than a normal value? 0.5 to 1.5 1.5 to 2.5 2.5 to 3.5 3.5 to 4.5
check the client's heart rate.
The nurse is administering medications on a medical-surgical unit. A client is ordered to receive 40 mg oral nadolol for the treatment of hypertension. Before administering the medication, the nurse should check the client's heart rate. check the client's serum K+ level. check the client's urine output. weigh the client.
Beta blocker ( Metoprolol is classified as a beta blocker. Beta blockers block beta adrenergic receptors of the sympathetic nervous system, causing vasodilation and decreased cardiac output and heart rate.)
The nurse is administering metoprolol to a client. What type of medication should the nurse educate the client about? Beta blocker Diuretic Angiotensin-converting enzyme (ACE) inhibitor Vasodilator
A ripping sensation in the chest ( Aortic dissections are commonly associated with poorly controlled hypertension. Dissection is caused by rupture in the intimal layer. A rupture may occur through adventitia or into the lumen through the intima, allowing blood to reenter the main channel and resulting in chronic dissection or occlusion of branches of the aorta. The onset of symptoms is usually sudden and described as severe, persistent pain that feels like tearing or ripping.)
The nurse is assessing a client with severe hypertension. Which symptom indicates to the nurse that the client is experiencing dissection of the aorta? Numbness and pain of the left arm Pain when flexing the neck forward Gradual onset of a frontal headache A ripping sensation in the chest
Dehydration
The nurse is caring for a 72-year-old client who has been admitted to the unit for a fluid volume imbalance. The nurse knows which of the following is the most common fluid imbalance in older adults? Hypovolemia Dehydration Hypervolemia Fluid volume excess
"Increase the amount of fruits and vegetables you eat."
The nurse is caring for a client who has had 25 mg of oral hydrochlorothiazide added to the medication regimen for the treatment of hypertension. Which instruction should the nurse give the client? "Take this medication before going to bed." "Increase the amount of fruits and vegetables you eat." "You may develop nasal congestion or depression while taking this medication." "You may drink alcohol while taking this medication."
Spironolactone
The nurse is caring for a client who is prescribed medication for the treatment of hypertension. The nurse recognizes that which medication conserves potassium? Furosemide Spironolactone Chlorothiazide Chlorthalidone
Avoid situations that contribute to ischemic episodes.
The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? Report changes in the usual pattern of chest pain. Avoid situations that contribute to ischemic episodes. Avoid fatty foods and exercise. Take over-the-counter decongestants.
continuous IV infusion
The nurse is caring for a client with a blood pressure of 210/100 mm Hg in the emergency room. What is the most appropriate route of administration for antihypertensive agents? continuous IV infusion sublingual intramuscular oral
in 3 to 5 days
The nurse is caring for a patient who has started anticoagulant therapy with warfarin (Coumadin). When does the nurse understand that therapeutic benefits will begin? Within 12 hours Within the first 24 hours In 2 days In 3 to 5 days
Changing positions slowly related to possible hypotension
The nurse is caring for an elderly client with a diagnosis of hypertension, who is taking several antihypertensive medications. Which safety precaution is the nurse most likely to reinforce? Changing positions slowly related to possible hypotension Eating extra potassium due to loss of potassium related to medications Being sure to keep follow-up appointments Walking as far as the client is able every day
It enhances the transport of glucose across the cell membrane.
The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action? It enhances the transport of glucose across the cell membrane. It aids in the process of gluconeogenesis. It stimulates the pancreatic beta cells. It decreases the intestinal absorption of glucose.
It carries glucose into body cells.
The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action? It carries glucose into body cells. It aids in the process of gluconeogenesis. It stimulates the pancreatic beta cells. It decreases the intestinal absorption of glucose.
heart rate heart rhythm Character of apical and peripheral pulses
The nurse is performing an assessment on a patient to determine the effects of hypertension on the heart and blood vessels. What specific assessment data will assist in determining this complication? (Select all that apply.) Heart rate Respiratory rate Heart rhythm Character of apical and peripheral pulses Lung sounds
NPH
The nurse is preparing to administer intermediate-acting insulin to a patient with diabetes. Which insulin will the nurse administer? NPH Iletin II Lispro (Humalog) Glargine (Lantus)
Takes high doses of vitamin D
A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider? Ingests alcohol occasionally Takes high doses of vitamin D Follows a high-fiber eating plan Works as a customer service representative
When mixing insulin, the regular insulin is drawn up into the syringe first.
The nurse is teaching a client about self-administration of insulin and about mixing regular and neutral protamine Hagedorn (NPH) insulin. Which information is important to include in the teaching plan? If two different types of insulin are ordered, they need to be given in separate injections. When mixing insulin, the NPH insulin is drawn up into the syringe first. When mixing insulin, the regular insulin is drawn up into the syringe first. There is no need to inject air into the bottle of insulin before withdrawing the insulin.
2 or fewer ( Two or fewer servings of lean meat, fish, and poultry are recommended in the DASH diet. The diet also recommends two or three servings of low-fat or fat-free dairy foods, four or five servings of fruits and vegetables, and seven or eight servings of grains and grain products.)
The nurse is teaching a client diagnosed with hypertension about the DASH diet. How many servings of meat, fish, and poultry should the client consume per day? 2 or fewer 2 or 3 4 or 5 7 or 8
there is no indication of target organ damage.
The nurse understands that an overall goal of hypertension management is that keep the blood pressure low. there is no indication of target organ damage. there is no report of postural hypotension. there are no reports of sexual dysfunction.
contrast phlebography.
The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is air plethysmography. contrast phlebography. lymphangiography. lymphoscintigraphy.
Teach the client how to apply an elastic sleeve
What should the nurse do to manage the persistent swelling in a client with severe lymphangitis and lymphadenitis? Teach the client how to apply an elastic sleeve Inform the physician if the client's temperature remains low Avoid elevating the area Offer cold applications to promote comfort and to enhance circulation
Ulcers and infection in the edematous area
What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Loose and wrinkled skin Ulcers and infection in the edematous area Evident scarring Cyanosis
Hyperkalemia
When administering benazepril with spironolactone, the nurse should be aware that which electrolyte imbalance may occur? Hyperkalemia Hypokalemia Hypercalcemia Hypocalcemia
1.5 to 2.5 times the baseline control. ( A normal PTT level is 21 to 35 seconds. A reading of more than 100 seconds indicates a significant risk of hemorrhage.)
When administering heparin anticoagulant therapy, the nurse needs to make certain that the activated partial thromboplastin time (aPTT) is within the therapeutic range of: 1.5 to 2.5 times the baseline control. 2.5 to 3.0 times the baseline control. 3.5 times the baseline control. 4.5 times the baseline control.
differ no more than 5 mm Hg between arms.
When measuring blood pressure in each arm of a healthy adult, the nurse recognizes that the pressures must be equal in both arms. may vary 10 mm Hg or more between arms. differ no more than 5 mm Hg between arms. may vary, with the higher pressure found in the left arm.
Pressures should not differ more than 5 mm Hg between arms.
When measuring the blood pressure in each arm of a healthy adult client, the nurse recognizes that which statement is true? Pressures must be equal in both arms. Pressures may vary 10 mm Hg or more between arms. Pressures should not differ more than 5 mm Hg between arms. Pressures may vary, with the higher pressure found in the left arm.
Anastomotic ( An anastomotic aneurysm occurs as a result of infection, arterial wall failure, and suture or graft failure)
Which aneurysm occurs as a result of infection at arterial suture or graft sites? Anastomotic False Dissecting Saccular
fruity breath ( The rising ketones and acetone in the blood can lead to acidosis and be detected as a fruity odor on the breath. Ketoacidosis needs to be treated to prevent further complications such as Kussmaul respirations (fast, labored breathing) and renal shutdown)
Which assessment finding is most important in determining nursing care for a client with diabetes mellitus? Respirations of 12 breaths/minute Cloudy urine Blood sugar 170 mg/dL Fruity breath
Hypokalemia and hypoglycemia
Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis? Hypokalemia and hypoglycemia Hypocalcemia and hyperkalemia Hyperkalemia and hyperglycemia Hypernatremia and hypercalcemia
Echocardiography
Which diagnostic method is recommended to determine whether left ventricular hypertrophy has occurred? Echocardiography Electrocardiography Blood chemistry Blood urea nitrogen
Chloride
Which electrolyte is a major anion in body fluid? Chloride Potassium Sodium Calcium
Retinal blood vessel damage
Which finding indicates that hypertension is progressing to target organ damage? Retinal blood vessel damage Urine output of 60 mL over 2 hours Blood urea nitrogen concentration of 12 mg/dL Chest x-ray showing pneumonia
"Test your blood glucose every 4 hours."
Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"? "Don't take your insulin or oral antidiabetic agent if you don't eat." "It's okay for your blood glucose to go above 300 mg/dl while you're sick." "Test your blood glucose every 4 hours." "Follow your regular meal plan, even if you're nauseous."
Intermittent claudication
Which of the following is the hallmark symptom for peripheral arterial disease (PAD) in the lower extremity? Intermittent claudication Acute limb ischemia Dizziness Vertigo
Using a BP cuff that is too small will give a higher BP measurement. The client's arm should be positioned at the level of the heart. The client should sit quietly while BP is being measured.
Which statements are true when the nurse is measuring blood pressure (BP)? Select all that apply. Using a BP cuff that is too small will give a higher BP measurement. The client's arm should be positioned at the level of the heart. Using a BP cuff that is too large will give a higher BP measurement. The client's BP should be measured 1 hour before consuming alcohol. The client should sit quietly while BP is being measured.
Secondary hypertension
Which term describes high blood pressure from an identified cause, such as renal disease? Primary hypertension Secondary hypertension Rebound hypertension Hypertensive emergency
rebound
Which term is refers to hypertension in which blood pressure that is controlled with therapy becomes uncontrolled (abnormally high) when the therapy is discontinued? Essential Primary Rebound Secondary
Lispro
Which type of insulin acts most quickly? Regular NPH Lispro Glargine
respiratory alkalosis ( This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis)
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:
respiratory alkalosis.
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: metabolic acidosis. metabolic alkalosis. respiratory acidosis. respiratory alkalosis.
114 mEq/L
A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into convulsions or a coma. What is the level of serum sodium at which a client can experience these side effects? 114 mEq/L 130 mEq/L 135 mEq/L 148 mEq/L
155 mEq/L (155 mmol/L)
A client has chronic hyponatremia, which requires weekly laboratory monitoring to prevent the client lapsing into convulsions or a coma. What is the level of serum sodium at which a client can experience these side effects? 114 mEq/L 130 mEq/L 135 mEq/L 148 mEq/L
Light-headedness or paresthesia
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? Headache or blurry vision Abdominal pain or diarrhea Hallucinations or tinnitus Light-headedness or paresthesia
Metabolic alkalosis
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis
metabolic alkalosis (A pH over 7.45 with a HCO3- level over 26 mEq/L indicates metabolic alkalosis.)
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? Respiratory alkalosis Metabolic alkalosis Respiratory acidosis Metabolic acidosis
tingling sensation in the fingers
A client is diagnosed with hypocalcemia and the nurse is teaching the client about symptoms. What symptom would the nurse include in the teaching? tingling sensation in the fingers polyuria flank pain hypertension
Moderate to severe arterial insufficiency ( Normal people without arterial insufficiency have an ABI of about 1.0. Those with an ABI of 0.95 to 0.5 have mild to moderate arterial insufficiency. Those with an ABI of less than 0.50 have ischemic rest pain. Those with tissue loss have severe ischemia and an ABI of 0.25 or less.)
A client is diagnosed with peripheral arterial disease. Review of the client's chart shows an ankle-brachial index (ABI) on the right of 0.45. This indicates that the right foot has which of the following? Moderate to severe arterial insufficiency No arterial insufficiency Very mild arterial insufficiency Tissue loss to that foot
Restricting fluids to 800 ml/day
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH? Restricting fluids to 800 ml/day Administering vasopressin as ordered Elevating the head of the client's bed to 90 degrees Restricting sodium intake to 1 gm/day
Constant, intense back pain and falling blood pressure
A client is hospitalized for repair of an abdominal aortic aneurysm. The nurse must be alert for signs and symptoms of aneurysm rupture and thus looks for which of the following? Constant, intense back pain and falling blood pressure Constant, intense headache and falling blood pressure Higher than normal blood pressure and falling hematocrit Slow heart rate and high blood pressure
Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute
A client is recovering from surgical repair of a dissecting aortic aneurysm. Which assessment findings indicate possible bleeding or recurring dissection? Urine output of 15 ml/hour and 2+ hematuria Blood pressure of 82/40 mm Hg and heart rate of 125 beats/minute Urine output of 150 ml/hour and heart rate of 45 beats/minute Blood pressure of 82/40 mm Hg and heart rate of 45 beats/minute
electrocardiogram (ECG) results
A client is taking spironolactone to control hypertension. The client's serum potassium level is 6 mEq/L. What is the nurse's priority during assessment? neuromuscular function bowel sounds respiratory rate electrocardiogram (ECG) results
Calcium ( calcium deficit is associated with the following symptoms: numbness and tingling of the fingers, toes, and circumoral region; positive Trousseau's sign and Chvostek's sign; seizures, carpopedal spasms, hyperactive deep tendon reflexes, irritability, bronchospasm, anxiety, impaired clotting time, decreased prothrombin, diarrhea, and hypotension.)
A client reports tingling in the fingers as well as feeling depressed. The nurse assesses positive Trousseau's and Chvostek's signs. Which decreased laboratory results does the nurse observe when the client's laboratory work has returned? Potassium Phosphorus Calcium Iron
Takes high doses of vitamin D ( Hypercalcemia can affect many organ systems and symptoms occur when the calcium level acutely rises. Hypercalcemia crisis refers to an acute rise in the serum calcium level. Severe thirst and polyuria are often present. Additional findings include muscle weakness, nausea, and bone pain. Excessive ingestion of vitamin D supplements may cause excessive absorption of calcium. Therefore, the nurse would report this finding to the health care provider.)
A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider? Ingests alcohol occasionally Takes high doses of vitamin D Follows a high-fiber eating plan Works as a customer service representative
Takes high doses of vitamin D ( Hypercalcemia can affect many organ systems and symptoms occur when the calcium level acutely rises. Hypercalcemia crisis refers to an acute rise in the serum calcium level. Severe thirst and polyuria are often present. Additional findings include muscle weakness, nausea, and bone pain. Excessive ingestion of vitamin D supplements may cause excessive absorption of calcium. Therefore, the nurse would report this finding to the health care provider.)
A client seeks medical attention for an acute onset of severe thirst, polyuria, muscle weakness, nausea, and bone pain. Which health history information will the nurse report to the health care provider? Ingests alcohol occasionally Takes high doses of vitamin D Follows a high-fiber eating plan Works as a customer service representative
dehydration
A client was admitted to the hospital unit after 2 days of vomiting and diarrhea. The client's spouse became alarmed when the client demonstrated confusion and elevated temperature, and reported "dry mouth." The nurse suspects the client is experiencing which condition? dehydration hypervolemia hypercalcemia hyperkalemia
metabolic alkalosis
A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance? metabolic alkalosis metabolic acidosis respiratory acidosis respiratory alkalosis
metabolic alkalosis ( Metabolic alkalosis results in increased plasma pH because of accumulated base bicarbonate or decreased hydrogen ion concentrations. The client's regular use of baking soda (sodium bicarbonate) may create a risk for this condition.)
A client who complains of an "acid stomach" has been taking baking soda (sodium bicarbonate) regularly as a self-treatment. This may place the client at risk for which acid-base imbalance? metabolic alkalosis metabolic acidosis respiratory acidosis respiratory alkalosis
165 mEq/L ( The normal sodium level is 135- 145 mEq/L (135-145 mmol/L). In hypernatremia, the serum sodium level exceeds 145 mEq/L (145 mmol/L) and the serum osmolality exceeds 300 mOsm/kg (300 mmol/L). The urine specific gravity and urine osmolality are increased as the kidneys attempt to conserve water (provided the water loss is from a route other than the kidneys). Body temperature may increase mildly, but it returns to normal after the hypernatremia is corrected.)
A client who is semiconscious presents with restlessness and weakness. The nurse assesses a dry, swollen tongue; body temperature of 99.3 °F; and a urine specific gravity of 1.020. What is the most likely serum sodium value for this client? 110 mEq/L 130 mEq/L 145 mEq/L 165 mEq/L
pH, 7.25; PaCO2 50 mm Hg
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? pH, 7.5; PaCO2 30 mm Hg pH, 7.40; PaCO2 35 mm Hg pH, 7.35; PaCO2 40 mm Hg pH, 7.25; PaCO2 50 mm Hg
pH, 7.25; PaCO2 50 mm Hg (In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 7.5 with a PaCO2value of 30 mm Hg indicates respiratory alkalosis. A ph value of 7.40 with a PaCO2 value of 35 mm Hg and a pH value of 7.35 with a PaCO2 value of 40 mm Hg represent normal ABG values, reflecting normal gas exchange in the lungs.)
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? pH, 7.5; PaCO2 30 mm Hg pH, 7.40; PaCO2 35 mm Hg pH, 7.35; PaCO2 40 mm Hg pH, 7.25; PaCO2 50 mm Hg
Prepare to assist with ventilation.
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? Prepare to assist with ventilation. Monitor the client's heart rhythm. Prepare for gastric lavage. Obtain a urine specimen for drug screening.
chronic respiratory acidosis ( Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.)
A client with emphysema is at a greater risk for developing which acid-base imbalance? chronic respiratory acidosis metabolic alkalosis metabolic acidosis respiratory alkalosis
chronic respiratory acidosis (Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.)
A client with emphysema is at a greater risk for developing which acid-base imbalance? chronic respiratory acidosis metabolic alkalosis metabolic acidosis respiratory alkalosis
furosemide
A client with severe hypervolemia is prescribed a loop diuretic and the nurse is concerned with the client experiencing significant sodium and potassium losses. What drug was most likely prescribed? furosemide hydrochlorothiazide metolazone spironolactone
Elevate the legs periodically for at least 15 to 20 minutes.
A client with venous insufficiency asks the nurse what they can do to decrease their risk of complications. What advice should the nurse provide to clients with venous insufficiency? Elevate the legs periodically for at least an hour. Avoid foods with iodine. Elevate the legs periodically for at least 15 to 20 minutes. Refrain from sexual activity for a week.
free water loss
A nurse evaluates a client's laboratory results. What is a factor that may be affecting an increase in serum osmolality? free water loss diuretic use overhydration hyponatremia
Numbness, cool skin temperature, and pallor
A nurse is assessing a client's right lower leg, which is wrapped with an elastic bandage. Which signs and symptoms suggest circulatory impairment? Numbness, cool skin temperature, and pallor Swelling, warm skin temperature, and drainage Numbness, warm skin temperature, and redness Redness, cool skin temperature, and swelling
Extracellular fluid volume deficit
A nurse is caring for an adult client with numerous draining wounds from gunshots. The client's pulse rate has increased from 100 to 130 beats per minute over the last hour. The nurse should further assess the client for which of the following? Extracellular fluid volume deficit Altered blood urea nitrogen (BUN) value Metabolic alkalosis Respiratory acidosis
The client had a liver transplant 2 years ago.
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? The client sees the health care provider for a check-up yearly. The client has never traveled outside of the country. The client had a liver transplant 2 years ago. The client works in a health insurance office.
forcing blood into the deep venous system.
A nurse is instructing a client about using antiembolism stockings. Antiembolism stockings help prevent deep vein thrombosis (DVT) by: encouraging ambulation to prevent pooling of blood. providing warmth to the extremity. elevating the extremity to prevent pooling of blood. forcing blood into the deep venous system.
weight
A nurse is providing an afternoon shift report and relates morning assessment findings to the oncoming nurse. Which daily assessment data is necessary to determine changes in the client's hypervolemia status? vital signs edema intake and output weight
bicarbonate-carbonic acid buffer system
A nurse is providing client teaching about the body's plasma pH and the client asks the nurse what is the major chemical regulator of plasma pH. What is the best response by the nurse? renin-angiotensin-aldosterone system bicarbonate-carbonic acid buffer system sodium-potassium pump ADH-ANP buffer system
Stop smoking.
A nurse is providing education about the prevention of arterial constriction to a client with peripheral arterial disease. Which of the following includes priority information the nurse would give to the client? Stop smoking. Keep your feet elevated above your heart. Wear antiembolic stockings daily to assist with blood return to the heart. Do not cross your legs for more than 30 minutes at a time.
Urine pH of 3.0 ( Normal urine pH is 4.5 to 8)
A nurse is reviewing a report of a client's routine urinalysis. Which value requires further investigation? Specific gravity of 1.02 Urine pH of 3.0 Absence of protein Absence of glucose
Respiratory alkalosis
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
Respiratory alkalosis ( a client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.)
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis
2.5 mEq/L
A patient is admitted with severe vomiting for 24 hours as well as weakness and "feeling exhausted." The nurse observes flat T waves and ST-segment depression on the electrocardiogram. Which potassium level does the nurse observe when the laboratory studies are complete? 4.5 mEq/L 5.5 mEq/L 2.5 mEq/L 3.5 mEq/L
Stabilizing heart rate and blood pressure and easing anxiety
A physician admits a client to the health care facility for treatment of an abdominal aortic aneurysm. When planning this client's care, which goal should the nurse keep in mind as she formulates interventions? Decreasing blood pressure and increasing mobility Increasing blood pressure and reducing mobility Stabilizing heart rate and blood pressure and easing anxiety Increasing blood pressure and monitoring fluid intake and output
Lactated Ringer's solution
A physician orders an isotonic I.V. solution for a client. Which solution should the nurse plan to administer? 5% dextrose and normal saline solution Lactated Ringer's solution Half-normal saline solution 10% dextrose in water
Monitoring respiratory status for signs and symptoms of pulmonary complications.
A priority nursing intervention for a client with hypervolemia involves which of the following? Establishing I.V. access with a large-bore catheter. Drawing a blood sample for typing and crossmatching. Monitoring respiratory status for signs and symptoms of pulmonary complications. Encouraging the client to consume sodium-free fluids.
130 mEq/L (130 mmol/L)
At which serum sodium concentration might convulsions or coma occur? 130 mEq/L (130 mmol/L) 145 mEq/L (145 mmol/L) 140 mEq/L (140 mmol/L) 142 mEq/L (142 mmol/L)
The client will be immobile during and shortly after surgery.
Following abdominal surgery, which factor predisposes a client to deep vein thrombosis? The client is 5' 9" tall and weighs 128 lb (58 kg). The client has been pregnant four times. The client usually walks 3 miles a day. The client will be immobile during and shortly after surgery.
three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad ( Ham (1,400 mg Na for 3 oz) and bacon (155 mg Na/slice) are high in sodium as is tomato juice (660 mg Na/¾ cup) and low fat cottage cheese (918 mg Na/cup). Packaged meals are high in sodium.)
Treatment of FVE involves dietary restriction of sodium. Which of the following food choices would be part of a low-sodium diet, mild restriction (2 to 3 g/day)? Three ounces of light or dark meat chicken, 1 cup of spaghetti and a garden salad Three ounces of sliced ham, beets, and a salad A frozen, packaged low-fat dinner with a side salad Tomato juice, low-fat cottage cheese, and three slices of bacon
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L
The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L pH: 7.40, PaCO2: 40 mm Hg, HCO3-: 24 mEq /L
Insensible fluid loss
The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? Lung function Summer allergies Cardiovascular compromise Insensible fluid loss
"I can use laxatives and enemas but only once a week."
The nurse is caring for a client diagnosed with bulimia. The client is being treated for a serum potassium concentration of 2.9 mEq/L (2.9 mmol/L). Which statement made by the client indicates the need for further teaching? "I can use laxatives and enemas but only once a week." "A good breakfast for me will include milk and a couple of bananas." "I will be sure to buy frozen vegetables when I grocery shop." "I will take a potassium supplement daily as prescribed."
155 mEq/L (155 mmol/L)
The nurse is caring for a client in the intensive care unit (ICU) following a near-drowning event in saltwater. The client is restless, lethargic, and demonstrating tremors. Additional assessment findings include swollen and dry tongue, flushed skin, and peripheral edema. The nurse anticipates that the client's serum sodium value would be 155 mEq/L (155 mmol/L) 145 mEq/L (145 mmol/L) 135 mEq/L (135 mmol/L) 125 mEq/L (125 mmol/L)
Avoid situations that contribute to ischemic episodes
The nurse is caring for a client with Raynaud's disease. What are important instructions for a client who is diagnosed with this disease to prevent an attack? Report changes in the usual pattern of chest pain. Avoid situations that contribute to ischemic episodes. Avoid fatty foods and exercise. Take over-the-counter decongestants.
confusion ( Normal serum concentration ranges from 135 to 145 mEq/L (135-145 mmol/L). Hyponatremia exists when the serum concentration decreases below 135 mEq/L (135 mmol/L). When the serum sodium concentration decreases to <115 mEq/L (<115 mmol/L), signs of increasing intracranial pressure, such as lethargy, confusion, muscle twitching, focal weakness, hemiparesis, papilledema, seizures, and death, may occur.)
The nurse is caring for a client with a serum sodium concentration of 113 mEq/L (113 mmol/L). The nurse should monitor the client for the development of which condition? Confusion Headache Nausea Hallucinations
Metabolic acidosis (Metabolic acidosis is a common clinical disturbance characterized by a low pH (increased H+ concentration) and a low plasma bicarbonate concentration.)
The nurse is caring for a patient with diabetes type I who is having severe vomiting and diarrhea. What condition that exhibits blood values with a low pH and a low plasma bicarbonate concentration should the nurse assess for? Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
A 52-year-old with diarrhea
The nurse is caring for four clients on a medical unit. The nurse is most correct to review which client's laboratory reports first for an electrolyte imbalance? A 7-year-old with a fracture tibia A 65-year-old with a myocardial infarction A 52-year-old with diarrhea A 72-year-old with a total knee repair
Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms.
The physician has prescribed 0.9% sodium chloride IV for a hospitalized client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply. Compare ABG findings with previous results. Maintain intake and output records. Document presenting signs and symptoms. Administer IV bicarbonate. Suction the client's airway.
0.45% sodium chloride
The physician has prescribed a hypotonic IV solution for a patient. Which IV solution should the nurse administer? 0.45% sodium chloride 0.9% sodium chloride 5% glucose in water 5% glucose in normal saline solution
contrast phlebography.
The term for a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot is air plethysmography. contrast phlebography. lymphangiography. lymphoscintigraphy.
1 L
The weight of a client with congestive heart failure is monitored daily and entered into the medical record. In a 24-hour period, the client's weight increased by 2 lb. How much fluid is this client retaining? 1 L 500 ml 1500 ml 1250 ml
Teach the client how to apply a graduated compression stocking.
What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis? Teach the client how to apply a graduated compression stocking. Inform the physician if the client's temperature remains low. Avoid elevating the area. Offer cold applications to promote comfort and to enhance circulation.
Teach the client how to apply a graduated compression stocking.
What should the nurse do to manage persistent swelling in a client with severe lymphangitis and lymphadenitis? Teach the client how to apply a graduated compression stocking. Inform the physician if the client's temperature remains low. Avoid elevating the area. Offer cold applications to promote comfort and to enhance circulation.
Ulcers and infection in the edematous area
What symptoms should the nurse assess for in a client with lymphedema as a result of impaired nutrition to the tissue? Loose and wrinkled skin Ulcers and infection in the edematous area Evident scaring Cyanosis
pH 7.48
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? HCO 21 mEq/L pH 7.48 PaCO 36 O saturation 95%
pH 7.48 (metabolic alkalosis is a clinical disturbance characterized by a high pH and high plasma bicarbonate concentration.)
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? HCO 21 mEq/L pH 7.48 PaCO 36 O saturation 95%
potassium
Which electrolyte is a major cation in body fluid? Chloride Bicarbonate Potassium Phosphate
potassium
Which electrolyte is a major cation in body fluid? Chloride Bicarbonate Potassium Phosphate
Confusion and seizures ( Classic signs of water intoxication include confusion and seizures, both of which are caused by cerebral edema. Weight gain will also occur)
Which findings indicate that a client has developed water intoxication secondary to treatment for diabetes insipidus? Confusion and seizures Sunken eyeballs and spasticity Flaccidity and thirst Tetany and increased blood urea nitrogen (BUN) levels
Contrast phlebography
Which of the following is a diagnostic test that involves injection of a contrast media into the venous system through a dorsal vein in the foot? Contrast phlebography Air plethysmography Lymphangiography Lymphoscintigraphy
Thoracic area
Which of the following is the most common site for a dissecting aneurysm? Thoracic area Lumbar area Sacral area Cervical area
Risk factor modification
Which of the following is the most effective intervention for preventing progression of vascular disease? Risk factor modification Use neutral soaps Avoid trauma Wear sturdy shoes
Kidney failure ( failure of the kidneys results in multiple fluid and electrolyte abnormalities including fluid volume overload. If renal function is so severely impaired that pharmacologic agents cannot act efficiently, other modalities are considered to remove sodium and fluid from the body.)
With which condition should the nurse expect that a decrease in serum osmolality will occur? Influenza Hyperglycemia Kidney failure Uremia
Atherosclerosis ( Atherosclerosis is the buildup of fats, cholesterol and other substances in and on the artery walls. This buildup is called plaque. The plaque can cause arteries to narrow, blocking blood flow. The plaque can also burst, leading to a blood clot.J)
You are presenting a workshop at the senior citizens center about how the changes of aging predisposes clients to vascular occlusive disorders. What would you name as the most common cause of peripheral arterial problems in the older adult? Aneurysm Coronary thrombosis Atherosclerosis Raynaud's disease
