Exam 1 AD Health

When assessing for potential side effects of fludrocortisone, what is a priority for the nurse to monitor? A. Serum potassium levels for hypokalemia B. Serum sodium levels for potential hyponatremia C. Serum calcium levels for hypercalcemia D. Intake and output for potential fluid volume deficit

B. Serum potassium levels for hypokalemia Rationale: Fludrocortisone has mineralocorticoid properties, resulting in sodium and fluid retention along with potassium excretion.

A patient admitted to the hospital with a diagnosis of pneumonia asks the nurse why she is receiving codeine when she is free of pain. What is the nurse's best response? A. "This medication will help increase lung volume." B. "This medication will help decrease your coughing." C. "This medication will help you bring up sputum." D. "This medication will strengthen your immune system."

B. "This medication will help decrease your coughing." Rationale: Codeine provides both analgesic and antitussive therapeutic effects. It does not strengthen the immune system, increase lung volume, or help the patient expectorate sputum.

With which client will the nurse be aware of an increased risk for hypoparathyroidism? A. A 28-year-old woman with pregnancy-induced hypertension B. A 35-year-old woman who had radiation therapy for Graves disease C. A 50-year-old man starting on insulin therapy for type 2 diabetes mellitus D. A 55-year-old man with moderate heart failure after myocardial infarction

B. A 35-year-old woman who had radiation therapy for Graves disease Rationale: Hypoparathyroidism is a relatively rare disorder. It is most often caused by treatment for hyperthyroidism that resulted in injury to the parathyroid glands. None of the other client health problems increase the risk for development of hypoparathyroidism.

What nursing diagnosis is a priority for a patient receiving desmopressin (DDAVP)? A. Risk for injury B. Fluid volume excess C. Knowledge deficit D. Alteration in comfort

B. Fluid volume excess Rationale: Desmopressin (DDAVP) is a form of antidiuretic hormone, which increases sodium and water retention, leading to an alteration in fluid volume. Although the other nursing diagnoses may be appropriate, they are not a priority using Maslow hierarchy of needs.

The nurse is teaching a patient with decreased hepatic function about taking pain relievers. What is the most important information to teach this patient? A. Do not take narcotic pain relievers. B. Take no more than 2 grams of acetaminophen per day. C. Do not take aspirin. D. Take COX-2 inhibitors every 8 hours.

B. Take no more than 2 grams of acetaminophen per day. Rationale: The patient with decreased hepatic function should decrease the dose of acetaminophen.

Which precaution will the nurse include when providing instructions to the female client with hypothyroidism who is prescribed to take thyroid hormone replacement therapy (HRT)? A. "Increase the amount of fiber in your diet to prevent the side effect of constipation." B. "Stop this drug immediately if you discover you are pregnant." C. "Avoid over-the-counter medications unless prescribed by your primary health care provider." D. "If you miss a dose, double your next day's dose."

C. "Avoid over-the-counter medications unless prescribed by your primary health care provider." Rationale: The amount of drug in synthetic thyroid hormone tablets is very small and many other foods and drugs interfere with its absorption. The client is instructed to not take over-the-counter medications without approval from the primary health care provider. Fiber greatly interferes with the drug's absorption and is not to be taken with or within 4 hours of HRT. In addition, the drug does not cause constipation. Thyroid HRT must continue during pregnancy. The therapy works best when blood levels are maintained. The client is taught to take the forgotten drug as soon as it is remembered and not to double the next day's dose.

Into which environment of care would the nurse anticipate sending a client who is experiencing complications from COVID-19? A. Medical home B. Community health care C. Inpatient care D. Rehabilitation care

C. Inpatient care

A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is most important for the nurse to communicate to the health care provider before the test? a. Bilateral poor peripheral vision b. Allergies to iodine and shellfish c. Recent weight loss of 20 pounds d. Complaints of ongoing headaches

b. Allergies to iodine and shellfish

A patient is admitted with a serum sodium level of 118 mEq/L. The nurse will anticipate the need for which diagnostic test? a. Urinary 17-ketosteroids b. Antidiuretic hormone level c. Growth hormone stimulation test d. Adrenocorticotropic hormone level

b. Antidiuretic hormone level

Which information about a patient with newly diagnosed diabetes mellitus will be most useful to the nurse in developing strategies for successful adaptation to this disease? a. Ideal weight b. Value system c. Activity level d. Visual changes

b. Value system

When reviewing the laboratory results for a patient's total calcium level, which information will the nurse need to consider? a. The blood glucose is elevated. b. The phosphate level is normal. c. The serum albumin level is low. d. The magnesium level is normal.

c. The serum albumin level is low.

The nurse will plan patient care that will decrease the patient's physical and emotional stress when the patient is undergoing a. a water deprivation test. b. testing for serum T3 and T4 levels. c. a 24-hour urine test for free cortisol. d. a radioactive iodine (I-131) uptake test.

c. a 24-hour urine test for free cortisol.

When evaluating the laboratory results for a patient with increased secretion of the anterior pituitary hormones, the nurse would expect to find a. decreased serum thyroxine levels. b. elevated serum aldosterone levels. c. an increase in urinary free cortisol. d. low urinary excretion of catecholamines.

c. an increase in urinary free cortisol.

The nurse is interviewing a patient who has a possible thyroid disorder. Which question will provide the most useful information? a. What methods do you use to help cope with stress? b. Have you experienced any blurring or double vision? c. Do you have to get up at night to empty your bladder? d. Have you had any recent unplanned weight gain or loss?

d. Have you had any recent unplanned weight gain or loss?

For which change reported by a client taking bromocriptine therapy to manage hyperpituitarism will the nurse notify the primary health care provider immediately to prevent harm? A. Chest pain B. Constipation C. Headache D. Increased sleepiness

A. Chest pain Rationale: Bromocriptine can cause serious cardiac dysrhythmias and coronary artery spasms.

For which symptoms will the nurse instruct the family and client who is being treated for diabetes insipidus (DI) to call 911 or go to the nearest emergency department? (Select all that apply.) A. Decreased urine output B. Hypotension C. Weigh gain of more than 2.2 lb (1 kg) in 24 hours D. Persistent headache E. Hyperglycemia F. Acute confusion

A. Decreased urine output C. Weight gain of more than 2.2lbs (1 kg) in 24 hours D. Persistent headache F. Acute confusion Rationale: Drug therapy for DI can cause a greatly increased kidney reabsorption of water and lead to life-threatening water toxicity. Indications of water toxicity are a relatively rapid onset of acute confusion, rapid weight gain, decreased urine output, persistent headache, and nausea and vomiting.

Which laboratory findings will the nurse use to validate the statement of a client with diabetes that therapy instructions for glucose control "have been followed to the letter" for the past 2 months? A. Random blood glucose level B. Glycosylated hemoglobin (HbA1c) C. Fasting blood insulin level D. Fasting blood glucose level

B. Glycosylated Hemoglobin (HbA1c) Rationale: The glycosylated hemoglobin (HbA1c) evaluates the average blood glucose level for 2 to 3 months; this is the best indicator of overall blood glucose control.

The nurse is teaching a patient who has been prescribed repaglinide. Which information should the nurse include in the teaching plan? A. "This medication is compatible with all of your cardiac medications." B. "This medication will not cause hypoglycemia." C. "This medication has no side effects." D. "You will need to be sure you eat as soon as you take this medication."

D. "You will need to be sure you eat as soon as you take this medication." Rationale: Repaglinide is a short-acting antidiabetic agent . The drug's very fast onset of action allows patients to take the drug with meals and skip a dose when they skip a meal. Repaglinide interacts with beta-adrenergic blockers as well as other medications. Hypoglycemia is a side effect of this medication, and there are many other possible side effects of this medication.

What is the nurse's best action when finding a patient with type 1 diabetes mellitus unresponsive, cold, and clammy? A. Administer subcutaneous regular insulin immediately. B. Start an insulin drip. C. Draw blood glucose level and send to the laboratory. D. Administer glucagon.

D. Administer glucagon. Rationale: Glucagon stimulates glycogenolysis, raising serum glucose levels. The patient is showing signs of hypoglycemia.

The patient is taking an antithyroid medication. Which foods should the nurse teach the patient to avoid eating? A. Ham and cheese omelet, rye toast with butter, orange juice B. Chicken salad sandwich with mayonnaise, vegetable soup, milk C. Hamburger on sesame roll, salad with French dressing, milk D. Shrimp cocktail, boiled lobster, spinach salad without dressing, water

D. Shrimp cocktail, boiled lobster, spinach salad without dressing, water Rationale: Seafood contains high amounts of iodine. The other choices do not. The nurse instructs a patient taking an antithyroid medication to avoid foods high in iodine.

The nurse is caring for a client who has been readmitted to the medical-surgical unit following surgery for a hernia repair completed under general anesthesia. What is the priority nursing assessment? A. Perform thorough auscultation of the lungs B. Assess response to pin-prick stimulation from feet to mid-chest level C. Determine level of consciousness and response to environmental stimuli D. Compare blood pressure findings from preoperative assessment to the present

A. Perform thorough auscultation of the lungs Rationale: After general anesthesia, which affects the entire body, the priority assessment is to determine that the client's level of consciousness has returned. All other assessment can be performed subsequently.

Which specific action is a priority for the nurse to teach a client with diabetes who has peripheral neuropathy to prevent harm? A. "Wear a medical alert bracelet." B. "Never go barefoot." C. "Never reuse insulin syringes." D. "Drink at least 3 L of fluids daily."

B. "Never go barefoot." Rationale: All the actions are important for the client with diabetes to perform for safety and to prevent a variety of complications. However, the most important action to prevent harm from peripheral neuropathy is to never go barefoot and wear shoes and slippers with firm soles.

When caring for a patient having a water deprivation test, which finding is most important for the nurse to communicate to the health care provider? a. The patient complains of intense thirst. b. The patient has a 5-lb (2.3 kg) weight loss. c. The patient feels dizzy when sitting up on the edge of the bed. d. The patients urine osmolality does not change after antidiuretic hormone (ADH) is given.

b. The patient has a 5-lb (2.3 kg) weight loss.

During a physical examination, the nurse finds that a patient's thyroid gland cannot be palpated. The most appropriate action by the nurse is to a. palpate the patient's neck more deeply. b. document that the thyroid was nonpalpable. c. notify the health care provider immediately. d. teach the patient about thyroid hormone testing.

b. document that the thyroid was nonpalpable.

When a patient in the outpatient clinic has an order for blood cortisol testing, which instruction will the nurse provide for the patient? a. Avoid adding any salt to your foods for 24 hours before the test. b. You will need to lie down for 30 minutes before the blood is drawn. c. Come to the laboratory to have the blood drawn early in the morning. d. Do not have anything to eat or drink before the blood test is obtained.

c. Come to the laboratory to have the blood drawn early in the morning.

When the nurse is caring for a patient who was admitted with tetany, which laboratory value should be monitored? a. Total protein b. Blood glucose c. Ionized calcium d. Serum phosphate

c. Ionized calcium

When a patient has clinical manifestations of hypothyroidism, which laboratory value should the nurse review to determine whether the hypothyroidism is caused by a problem with the anterior pituitary gland or with the thyroid gland? a. Thyroxine (T4) level b. Triiodothyronine (T3) level c. Thyroid-stimulating hormone (TSH) level d. Thyrotropin-releasing hormone (TRH) level

c. Thyroid-stimulating hormone (TSH) level

When working with a patient who has diabetes mellitus, the nurse reviews the results of testing for glycosylated hemoglobin (HbA1C) to evaluate for a. glucose levels 2 hours after a meal. b. circulating, nonfasting glucose levels. c. glucose control over the past 3 months. d. hypoglycemic episodes in the past 90 days.

c. glucose control over the past 3 months.

When the nurse is obtaining the health history, which statement by a patient indicates further assessment of thyroid function may be necessary? a. I notice my breasts are tender lately. b. I am so thirsty that I drink all day long. c. I get up several times at night to urinate. d. I feel a lump in my throat when I swallow.

d. I feel a lump in my throat when I swallow.

Which information about a patient who is scheduled for an oral glucose tolerance test should be reported to the health care provider before starting the test? a. The patient reports having occasional orthostatic dizziness. b. The patient has had a 10-pound weight gain in the last month. c. The patient drank several glasses of water an hour previously. d. The patient takes oral corticosteroids for rheumatoid arthritis.

d. The patient takes oral corticosteroids for rheumatoid arthritis.

A patient has a total serum calcium level of 13.3 mg/dL (3.3 mmol/L). The nurse will anticipate the need to teach the patient about testing for a. calcitonin levels. b. catecholamine levels. c. thyroid hormone levels. d. parathyroid hormone levels.

d. parathyroid hormone levels.

A patient is scheduled for a growth hormone stimulation test. In preparation for the test, the nurse will obtain a a. basin of ice. b. cardiac monitor. c. vial of glargine insulin. d. vial of 50% dextrose solution.

d. vial of 50% dextrose solution.

The nurse admitting a patient with acromegaly anticipates administering which medication? A. Somatropin B. Desmopressin C. Octreotide D. Corticotropin

C. Octreotide Rationale: Octreotide suppresses growth hormone that causes acromegaly.

What is the nurse's best response when family members of a client with hyperthyroidism express concern about the client's frequent mood swings? A. "Do the client's mood swings make you feel angry?" B. "The medications will make the mood swings disappear completely." C. "Your family member is sick. You must be patient." D. "Mood swings are common should diminish with treatment."

D. "Mood swings are common should diminish with treatment." Rationale: Telling the family that the client's mood swings should diminish over time with treatment provides information to the family, as well as reassurance that this behavior is expected.

A client has just undergone a surgical procedure with general anesthesia. Which finding indicates that the client needs further nursing assessment? A. Pain at the surgical site B. Verbal stimuli needed to awaken C. Sore throat upon swallowing D. Snoring sounds when inhaling

D. Snoring sounds when inhaling Rationale: Snoring sounds when inhaling may indicate respiratory depression.

A patient is scheduled for a 24-hour urine collection for 17-ketosteroids. The nurse will need to a. keep the specimen on ice. b. insert a retention catheter. c. have the patient void and save that specimen to start the collection. d. encourage the patient to drink 2 to 3 L of fluid during the 24 hours.

b. insert a retention catheter.

When a patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, the nurse will monitor for a. decreased urinary output. b. evidence of fluid overload. c. increased serum sodium levels. d. elevated serum potassium levels.

d. elevated serum potassium levels.

Which statement by a client indicates to the nurse correct understanding of what to do when the sensations of hunger and shakiness occur? A. "I will eat three graham crackers." B. "I will drink a glass of water." C. "I will sit down and rest." D. "I will give myself a dose of glucagon."

A. "I will eat three graham crackers." Rationale: Feeling hungry and shaky are symptoms of mild hypoglycemia. Correct understanding of what the client needs to do when these symptoms occur is to eat three graham crackers. This is the correct management strategy for mild hypoglycemia.

After instructing a client about the correct procedure for a 24-hour urine test, which client statement indicates to the nurse a need for further teaching? A. "I will not eat any fatty foods when I am collecting urine for this test." B. "To end the collection, I must empty my bladder and add this urine to the collection." C. "I need to keep the urine container cool in a separate refrigerator or cooler." D. "I won't save the first urine sample of the day."

A. "I will not eat any fatty foods when I am collecting urine for this test." Rationale: A need for further teaching is needed when the client says that he/she will not eat any fatty foods while collecting urine for a 24-hour urine test to evaluate a hormone level. Eating fatty foods does not interfere with collection or testing of the urine sample. The other statements indicate correct understanding of the client's actions for collection of an accurate 24-hour urine specimen.

Which statement indicates to the nurse that the patient needs additional teaching on oral hypoglycemic agents? A. "I will take the medication only when I need it." B. "I will report symptoms of fatigue and loss of appetite." C. "I will limit my alcohol consumption." D. "I will monitor my blood sugar daily."

A. "I will take the medication only when I need it." Rationale: Oral hypoglycemic agents must be taken on a daily scheduled basis to maintain euglycemia and prevent long-term complications of diabetes. When alcohol is ingested with certain oral hypoglycemic drugs, the hypoglycemic effect can be intensified. The patient may experience fatigue and loss of appetite as side effects of the medication, and these should be reported to the health care provider. The patient needs to closely monitor blood sugar.

Which statement made by a client about thyroid hormone replacement therapy (HRT) indicates to the nurse that further teaching is needed? A. "If I continue to lose weight, I may need an increased dose." B. "I will have more energy with this medication." C. "If I often am constipated and feel tired, I may need an increased dose." D. "I will take the medication every morning."

A. "If I continue to lose weight, I may need an increased dose." Rationale: The statement, "If I continue to lose weight, I may need an increased dose," indicates a need for further teaching. Weight loss indicates a need for a decreased dose, not an increased dose.One of the symptoms of hypothyroidism is lack of energy. Thyroid replacement therapy would cause the client to have more energy. The correct time to take thyroid replacement therapy is in the morning. Frequent constipation and continuing to feel tired are indications that the dose may need to be increased.

What action will the nurse advise to prevent harm for a client with diabetes who has a 3-cm callus on the ball of the right foot? A. "Make an appointment with your podiatrist as soon as possible." B. "Make an appointment with a pedicurist and have them cut or file off the callus." C. "Soak your feet nightly in warm water and peel of a little of the callus every day." D. "Apply an over-the-counter callus-dissolving pad and follow the package directions."

A. "Make an appointment with your podiatrist as soon as possible." Rationale: The client with diabetes is taught to see his or her diabetes health care provider or a podiatrist for calluses, corns, or any other foot lesion and never to self-treat such problems. The risk for development of an ongoing injury with chronic infection is very high could lead to eventual amputation.

Which statement made by a client who is learning about self-injection of insulin indicates to the nurse that clarification is needed about injection site selection and rotation? A. "The abdominal site is best because it is closest to the pancreas." B. "I can reach my thigh best, so I will use different areas of the same thigh." C. "If I change my injection site from the thigh to an arm, the inulin absorption may be different." D. "By rotating sites within one area, my chance of having skin changes is less."

A. "The abdominal site is best because it is closest to the pancreas." Rationale: The abdominal site has the fastest and most consistent rate of absorption because of the blood vessels in the area and not because of its proximity to the pancreas. The other statements demonstrate correct understanding about injection site selection and rotation.

The nurse is evaluating factors that influence care for a client with diabetes. Which client statement does the nurse identify that reflects a social determinant of health? A. "The grocery store in my neighborhood went out of business." B. "The landlord of my apartment is putting in an access ramp for wheelchairs." C. "I work with a lot of toxic chemicals in my job." D. "Because I live on the bus line, I can ride over to park if I want to get fresh air."

A. "The grocery store in my neighborhood went out of business." Rationale: Social determinants of health include availability of resource to meet daily needs, such as healthful foods.

The patient newly diagnosed with type 2 diabetes mellitus has been ordered insulin glargine. What information is essential for the nurse to teach this patient? A. "This medication has a duration of action of 24 h." B. "This medication should be mixed with the regular insulin each morning." C. "This medication is very expensive, but you will be receiving it only a short time." D. "This medication is very short acting. You must be sure you eat after injecting it."

A. "This medication has a duration of action of 24 h." Rationale: Insulin glargine has a duration of action of 24 h with no peaks, mimicking the natural, basal insulin secretion of the pancreas. This medication cannot be mixed with other insulins and is not a short-acting insulin. The patient may need to receive this medication for a long time.

The nurse has prepared a client for transport from the medical-surgical unit to surgery. Which client statement will the nurse respond to as the priority? A. "When I eat shrimp, my tongue swells and I have trouble breathing." B. "I'm feeling more anxious about my surgery than I thought I would be." C. "I'm not sure what I will do if insurance doesn't cover this expensive hip replacement." D. "My sister had anesthesia a few months ago and she said she did not like the way she felt."

A. "When I eat shrimp, my tongue swells and I have trouble breathing." Rationale: An allergy to iodine or shellfish indicates a risk for a reaction to the agents used to clean the surgical area. With this knowledge about the client, the nurse must intervene immediately. All other statements can be responded to after addressing the shrimp allergy.

The nurse should include which statement when teaching a patient about insulin glargine? A. "You cannot mix this insulin with any other insulin in the same syringe." B. "You can mix this insulin with Lente insulin to enhance its effects." C. "The duration of action for this insulin is approximately 8-10 h, so you will need to take it twice a day." D. "You should inject this insulin just before meals because it is very fast acting."

A. "You cannot mix this insulin with any other insulin in the same syringe." Rationale: Insulin glargine is a long-acting insulin with a duration of action up to 24 h. It should not be mixed with any other insulins. The insulin is not fast acting.

A 30-year-old male client having an annual health physical reports that all of the following changes have developed during the past year. Which ones alert the nurse to possible pituitary hyperfunction? Select all that apply. A. 15 lb weight gain B. Decreased libido C. Four sinus infections D. Frequent constipation E. Increased foot callus formation F. Occasional dripping of clear fluid from both breasts G. Severely sprained ankle from a volley ball injury

A. 15 lb weight gain B. Decreased libido F. Occasional dripping of clear fluid from both breasts Rationale: Several hormones secreted in excess can cause weight gain, although so can increased caloric intake and decreased energy output. However in this instance it is occurring along with other indicators of pituitary hyperfunction. Decreased libido is associated with increased prolactin production, as well as decreased gonadotropins. Galactorrhea (leaking of fluid from the breast) in a man is associated with excess prolactin. Increased sinus infections are not associated with changing pituitary hormone levels. Constipation could be associated with decreased thyroid stimulating hormone but not pituitary hyperfunction. Callus formation and a sprained ankle are physical responses not related to endocrine function.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 26 year old with type 1 diabetes whose insulin pump is beeping "occlusion." B. A 30 year old with type 1 diabetes who is reporting thirst. C. A 40 year old with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L). D. A 50 year old with type 2 diabetes with a blood pressure of 150/90 mm Hg.

A. A 26 year old with type 1 diabetes whose insulin pump is beeping "occlusion." Rationale: The client the nurse sees first is the client with type 1 diabetes whose insulin pump is beeping "occlusion." Because glucose levels will increase quickly in clients whose continuous insulin pumps malfunction, the nurse must assess this client and the insulin pump first to avoid hyperglycemia or diabetic ketoacidosis.

Which client does the nurse identify at greatest risk for slow wound healing? A. A 47-year-old man with obesity and diabetes B. A 58-year-old woman who smokes 2 packs of cigarettes daily C. A 78-year-old man with controlled hypertension D. A 21-year-old woman with an STI

A. A 47-year-old man with obesity and diabetes Rationale: Obesity and diabetes significantly place a client at greatest risk for slow wound healing.

The nurse is teaching a client about postoperative leg exercises. What teaching will the nurse include? Select all that apply. A. Begin practicing leg exercises prior to surgery. B. Repeat leg exercises several times daily for each leg. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch.

A. Begin practicing leg exercises prior to surgery. C. Push the ball of the foot into the bed until the calf and thigh muscles contract. D. If pain or warmth in the calf is present, discontinue exercises and contact the surgeon. E. Point toes of one foot toward bed bottom; then point toes of same leg toward face. Switch. Rationale: Teaching regarding postoperative leg exercises should include having the client begin practicing the exercises before surgery; repeating the exercises several times daily for each leg; pushing the ball of the foot into the bed until the calf and thigh muscles contract; discontinuing exercises and contacting the surgeon if pain of warmth in the calf is present; and pointing toes of one foot towards the bottom of the bed, then towards the face, and switching.

Which trends in serum electrolyte values will the nurse expect to find in a client who has untreated hypoparathyroidism? A. Below normal calcium levels; above normal phosphorus levels B. Below normal calcium levels; below normal phosphorus levels C. Above normal calcium levels; above normal phosphorus levels D. Above normal calcium levels; below normal phosphorus levels

A. Below normal calcium levels; above normal phosphorus levels Rationale: With hypoparathyroidism, the lack of parathyroid hormone (PTH) decreases serum calcium levels by increasing kidney calcium excretion and inhibiting calcium absorption from the GI tract. Low levels of calcium cause a corresponding increase in serum phosphorus levels because calcium and phosphorus exist in a balanced reciprocal relationship in which a decrease in one always causes an increase in the other.

Which action immediately after a hypophysectomy will the nurse instruct a client to avoid to prevent harm? (Select all that apply.) A. Bending at the waist B. Talking C. Deep breathing D. Coughing E. Wearing makeup F. Using dental floss

A. Bending at the waist D. Coughing Rationale: Coughing early after surgery both increases intracranial pressure (ICP) and also increases pressure in the incision area and may lead to a leak of cerebrospinal fluid. Bending at the waist also increases ICP.

In the early postoperative period, which assessment finding in a client who had an epidural during surgery requires immediate nursing intervention? A. Blood pressure of 142/90 B. Headache of 4 on a 1-10 scale C. Gradual return of motor function D. Increase in back pain when coughing

A. Blood pressure of 142/90 Rationale: An increase in back pain can be indicative of an epidural hematoma; therefore, the nurse will immediately address this finding. Blood pressure can be compared to baseline after addressing the back pain, as can the headache. The nurse can continue to monitor the expected, gradual return of motor function.

Which action in the plan of care for a client who is hospitalized for pituitary function testing would be most appropriate for the nurse to delegate to an experienced assistive personnel (AP)? A. Checking the client's blood glucose levels every 4 hours B. Monitoring the client's response to the IV insulin given during a stimulation test C. Teaching the client about a hormone suppression test D. Assessing the client for symptoms of hypopituitarism

A. Checking the client's blood glucose levels every 4 hours Rationale: Monitoring blood glucose is within the nursing assistant's scope of practice if the nursing assistant has received education and evaluation in the skill.

Which factor does the nurse identify that influences client outcomes? (Select all that apply.) A. Collaboration between members of the interprofessional health care team B. Health policy legislation at the state and national level C. The culture to which the client identifies D. What the individual client believes about health? E. Technology that is available in the local community health center F. The application of systems thinking to care of clients

A. Collaboration between members of the interprofessional health care team B. Health policy legislation at the state and national level C. The culture to which the client identifies D. What the individual client believes about health? E. Technology that is available in the local community health center F. The application of systems thinking to care of clients Rationale: Knowledge and experience of the health care professional influence client outcomes. Other factors that directly influence client outcomes include:· Behavioral and social determinants of health: What "health" means to each client within the context of his or her culture· New approaches to population health management: evidence-based care that is delivered to individuals, communities, and populations· Policy and health care reform: legislation at all levels of government, which influence health care as a right rather than a privilege· Available and emerging technologies: the use of which assesses for health risks and influences treatment plans· Interprofessional practice: the collaboration of all health care team members who are focused on patient-centered care· Shift towards systems thinking: the recognition that health maintenance, health care activities, and health care interventions do not occur in isolation, and that lessons can be learned from individual care that pertains to a larger group of patients (and vice versa).

Which action best exemplifies the expected outcome of appropriate negative feedback control over endocrine gland hormone secretion? A. Decreased secretion of glucagon when blood glucose approaches normal levels B. Increased secretion of parathyroid hormone in response to a calcium-containing intravenous infusion C. Increased secretion of thyroid stimulating hormone in response to long-term exogenous thyroid hormone replacement therapy D. Decreased secretion of cortisol in response to a pituitary tumor stimulating the increased secretion of adrenocorticotropic hormone

A. Decreased secretion of glucagon when blood glucose approaches normal levels. Rationale: A negative feedback mechanism signals an endocrine gland to secrete a hormone in response to a body change to cause a reaction that will result in actions to oppose the action of the initial condition change and restore homeostasis. Serum calcium levels determine when and to what degree parathyroid hormone PTH is released. PTH secretion decreases when serum calcium levels are high, and it increases when serum calcium levels are low. If thyroid hormone levels are high, as would be the case if a client was taking exogenous thyroid hormone replacement therapy, release of both thyrotropin-releasing hormone (TRH) and thyroid stimulating hormone TSH is inhibited. Adrenocorticotropic hormone (ACTH) triggers the release of cortisol from the adrenal cortex, not suppression of its release.

Which nursing action reflects the process of prioritize hypotheses, per the NCSBN Clinical Judgement Measurement Model (CJMM)? A. Determining that a new blood pressure reading of 190/100 requires intervention now. B. Obtaining vital signs every 4 hours and noting a client's blood pressure as 130/90. C. Administering amlodipine 5 mg orally once daily D. Contacting the registered dietician nutritionist (RDN) to evaluate a client's salt intake.

A. Determining that a new blood pressure reading of 190/100 requires intervention now. Rationale: Prioritizing hypotheses is the act of considering all possibilities and determining their relative urgency and risk to the client. The nurse who has determined that a blood pressure reading of 190/100 requires nursing intervention now has performed prioritization. Administering medication and contacting a member of the interprofessional health care team reflects the CJMM process of take action.

Which signs and symptoms in a client who has hyperthyroidism indicate to the nurse possible progression to a thyroid storm? (Select all that apply.) A. Elevated temperature B. Tachycardia C. Somnolence D. Elevated systolic blood pressure E. Abdominal pain and nausea F. Slow respiratory rate

A. Elevated temperature B. Tachycardia D. Elevated systolic blood pressure E. Abdominal pain and nausea Rationale: Symptoms of thyroid storm are caused by excessive thyroid hormone release, which dramatically increases metabolic rate. Key symptoms include fever, tachycardia, and systolic hypertension. Additional symptoms include abdominal pain, nausea, vomiting, diarrhea, tremors, and anxiety.The increased metabolic rate causes the respiratory rate to increase. Clients are agitated, not somnolent.

What is the nurse's best action when noticing that the phlebotomist, who plans to draw blood from the client with severe hypercortisolism, displays symptoms of a cold? A. Ensuring the phlebotomist wears a facemask while in the client's room B. Asking the phlebotomist to delay the blood draw C. Monitoring the client closely for cold-like symptoms D. Placing a facemask on the client

A. Ensuring the phlebotomist wears a facemask while in the client's room Rationale: The nurse needs to make sure the phlebotomist wears a facemask because the client is immunosuppressed and at higher risk for respiratory infection. Anyone with a suspected upper respiratory infection who must enter the client's room needs to wear a mask to prevent the spread of infection.Asking the phlebotomist to delay the blood draw could lead to harm by not providing sufficient information about the client's condition. The phlebotomist, not the client, is exhibiting cold-like symptoms, so monitoring the client for these symptoms is not appropriate. Having the client wear a mask during the blood draw does not protect him or her from any airborne microorganisms that remain in the atmosphere of the room or droplets that may reside on surfaces.

The nurse is discussing how context influences clinical judgment. What nursing considerations reflect context? (Select all that apply.) A. Environment of care B. Taking a client's temperature C. Availability of electronic health records D. Time pressures within the unit E. Individual nursing knowledge

A. Environment of care C. Availability of electronic health records D. Time pressures within the unit E. Individual nursing knowledge Rationale: The most important part of the CJMM is that another layer—the context of the situation—considers and supports clinical judgment. The factors within this layer, such as environment, time pressure, availability or content of electronic health records, resources, and individual nursing knowledge, have a direct impact on clinical judgment.

Which assessment has the highest priority for the nurse to perform for a client with syndrome of inappropriate antidiuretic hormone (SIADH) receiving tolvaptan therapy for 24 hours? A. Evaluating serum sodium levels B. Evaluating serum potassium levels C. Examining the skin and sclera for jaundice D. Examining the IV site for indications of phlebitis

A. Evaluating serum sodium levels Rationale: Tolvaptan carries a black box warning of increased risk for developing hypernatremia within 12 to 24 hours that can lead to CNS demyelination and death. Serum potassium levels are not directly affected by this drug. Although the drug is associated with an increased risk for jaundice, this problem appears after 30 days of use. Tolvaptan is an oral drug, not a parenteral one.

Which physiological processes directly prevent severe hypoglycemia in a healthy adult without diabetes who is NPO for 12 hours? Select all that apply. A. Gluconeogenesis B. Glycogenesis C. Glycogenolysis D. Ketogenesis E. Lypogenesis F. Lypolysis

A. Gluconeogenesis C. Glycogenolysis Rationale: Gluconeogenesis is the conversion of protein into glucose. This process increases blood glucose levels and prevents hypoglycemia during fasting. Glycogenolysis is the breakdown of stored glycogen in the liver and skeletal muscle and conversion to glucose. It is the main process that prevents hypoglycemia during fasting. Glycogenesis is the conversion by the liver of excess circulating glucose into glycogen. This process reduces blood glucose levels and does not directly prevent hypoglycemia. Ketogenesis is the breakdown of fats (lipids) into ketone bodies that can be used for fuel by some cells. It does not raise blood glucose levels and does not directly prevent hypoglycemia. Lypogenesis is the conversion of glucose (and other substances) into body fats, usually as free fatty acids. This process does not prevent hypoglycemia during fasting. Lypolysis is the breakdown of fatty acids but does not convert them to glucose and does not directly prevent hypoglycemia during fasting.

What should the nurse teach the patient to minimize gastrointestinal (GI) side effects of opioid analgesics for chronic pain? A. Increase fluid and fiber in the diet. B. Take diphenoxylate hydrochloride and atropine sulfate with each dose. C. Take the medication on an empty stomach. D. Eat foods high in lactobacilli.

A. Increase fluid and fiber in the diet. Rationale: Opioid analgesics decrease intestinal motility, leading to constipation. Increasing fluid and fiber in the diet can prevent this. Eating foods high in lactobacilli and taking the medication on an empty stomach will not minimize GI side effects and may intensify them. Lomotil is used to treat diarrhea rather than the constipation that would result from use of narcotic analgesics.

Which client assessment finding indicates to the nurse the need to assess further for a possible endocrine problem? A. Increased facial hair and absent menses in a 28-year-old nonpregnant woman B. Increased appetite in a 40-year-old man who started an aerobic exercise program 1 week ago C. Male-pattern baldness in a 32-year-old man D. Dry skin on the shins of a 70-year-old woman

A. Increased facial hair and absent menses in a 28-year-old nonpregnant women. Rationale: Absence of menses when pregnancy is not present is considered abnormal, especially when accompanied by hirsutism. Possible endocrine problems associated with these changes include ovarian, adrenal gland, hypothalamic, or anterior pituitary dysfunction. Male-pattern baldness in a man is usually associated with a genetic predisposition. Dry skin is a normal finding in older women. An increased appetite when physical activity increases is also considered normal.

What assessment finding indicates to the nurse that vasopressin has been effective? A. Increased urine specific gravity B. Increased serum albumin levels C. Relief of pain D. Decreased adrenocorticotropic hormone levels

A. Increased urine specific gravity Rationale: Vasopressin causes decreased water excretion in the renal tubule, thus increasing urine specific gravity. It is used to treat diabetes insipidus, which presents with a low urine specific gravity. This medication does not affect serum albumin, decrease adrenocorticotropic hormone levels, or decrease pain.

The nurse is completing a preoperative physical assessment for a client who will have surgery this afternoon. Which assessment finding will the nurse report to the operative team? Select all that apply. A. Left arm prosthesis B. Skin turgor < 3 seconds C. Blood pressure 160/100 D. Presence of chest rigidity E. Has been NPO since midnight F. Expressed concern about surgery payment

A. Left arm prosthesis C. Blood pressure 160/100 D. Presence of chest rigidity Rationale: The nurse will report assessment findings of a left arm prosthesis (as this must be addressed prior to surgery); blood pressure of 160/100 (as this is high, which may delay surgery); and the presence of chest rigidity (which is an abnormal finding that may indicate respiratory compromise which could affect whether surgery takes place) to the operative team. The findings of skin turgor of < 3 seconds, adherence to the NPO plan, and a natural concern about payment for surgery do not require reporting to the operative team.

Which environments of care will the nurse recognize as components of the healthcare system? Select all that apply. A. Long term care B. Primary care C. Free standing emergency department D. National League of Nursing E. Patient-centered medical home F. World Health Organization

A. Long term care B. Primary care C. Free standing emergency department E. Patient-centered medical home Rationale: Long term care, primary care, free standing emergency department, and the patient-centered medical home are environments of care. The National League for Nursing and the World Health Organization are not environments of care.

A patient with type 1 diabetes mellitus has been ordered insulin aspart 10 units at 7:00 AM. What nursing intervention should the nurse perform after administering this medication? A. Make sure the patient eats breakfast immediately. B. Perform a fingerstick blood sugar test. C. Flush the IV. D. Have the patient void and dipstick the urine.

A. Make sure the patient eats breakfast immediately. Rationale: Insulin aspart is a rapid-acting insulin that acts in 15 min or less. It is imperative that the patient eats as it starts to work. The patient should have had a fingerstick blood sugar test done before receiving the medication. There is no need to check the urine. This medication is given subcutaneously.

Performance of which assessment is a priority for the nurse before giving a client the first oral dose of hormone replacement for hypothyroidism? A. Measuring heart rate and rhythm B. Checking core body temperature C. Asking about previous allergic drug reactions D. Listening to bowel sounds in all four abdominal quadrants

A. Measuring heart rate and rhythm Rationale: The side effects and adverse effects of thyroid hormone replacement drugs increase metabolic rate and cardiac activity. Checking heart rate and rhythm before giving the drug provides a baseline to determine whether or not the drug is working correctly or is causing an overdose effect. Although changes in core body temperature and bowel sounds will eventually indicate responses to the prescribed therapy, the most critical to assess are those related to cardiac function. Thyroid replacement hormone has not been taken by this client before and is not associated with any other types of drug allergies.

Which new-onset symptoms will the nurse instruct a client with diabetes who is prescribed to take the sodium-glucose cotransport inhibitor, empagliflozin, to report to the diabetes health care provider to prevent harm? (Select all that apply.) Select all that apply. A. Muscle weakness and dizziness on standing B. Redness and tenderness at the injection site C. Rapid weight gain and shortness of breath D. Redness and tenderness of the perineum E. Sensations of hunger, tremors, sweating, and confusion F. Pain and burning on urination

A. Muscle weakness and dizziness on standing D. Redness and tenderness of the perineum E. Sensations of hunger, tremors, sweating, and confusion F. Pain and burning on urination Rationale: Drugs from the lower blood glucose levels by preventing kidney reabsorption of glucose and sodium that was filtered from the blood into the urine. This filtered glucose is excreted in the urine rather than moved back into the blood. Hypoglycemia (symptoms of hunger, tremors, sweating, confusion) is possible as is dehydration with excessive sodium loss (muscle weakness and orthostatic hypotension with dizziness on standing). The excess glucose in the urine increases the risk for urinary tract infections with pain and burning on urination. These drugs increase the risk for Fournier gangrene with perineal fasciitis, which has early symptoms of redness and tenderness of the perineal skin. The drug is taken orally and not by injection. It is not associated with heart failure that may manifest with symptoms of rapid weight gain and shortness of breath.

The nurse is preparing to administer an injection of morphine to a patient and notes a respiratory rate of 10 breaths/min. What is the nurse's best action? A. Notify the health care provider and delay drug administration. B. Administer the prescribed dose and notify the health care provider. C. Administer a smaller dose and record the findings. D. Hold the drug, record the assessment, and recheck in 1 hour.

A. Notify the health care provider and delay drug administration. Rationale: Respiratory depression is a side effect of opioid analgesia. Therefore, since the patient's respiratory rate is below normal, the nurse should withhold the morphine and notify the health care provider. The drug should not be given while the respiratory rate is this much low, and the health care provider should be notified of the change in the patient's condition.

Which precaution is a priority for the nurse to teach a client prescribed semaglutide to prevent harm? A. Only take this drug once weekly. B. Report any vision changes immediately. C. Do not mix in the same syringe with insulin. D. This drug can only be given by a health care professional.

A. Only take this drug once weekly. Rationale: Semaglutide is a long-acting GLP-1 agonist given only once weekly and comes only as a self-injection pen. It does not have to be administered by a health care professional. It is not associated with any vision changes.

Which change in serum electrolyte values in the past 12 hours for a client with syndrome of inappropriate antidiuretic hormone (SIADH) being treated with tolvaptan will the nurse report immediately to the health care provider? A. Serum sodium increases from 122 mEq/L to 140 mEq/L. B. Serum potassium decreases from 4.2 mEq/L to 3.8 mEq/L. C. Serum chloride decreases from 109 mEq/L to 99 mEq/L. D. Serum calcium increases from 9.5 mg/dL to 10.2 mg/dL.

A. Serum sodium increases from 122 mEq/L to 140 mEq/L. Rationale: The purpose of tolvaptan is to restore a normal sodium concentration to the blood and other extracellular fluid. In the case of syndrome of inappropriate antidiuretic hormone, excessive amounts of antidiuretic hormone have caused more water to be absorbed, causing the serum sodium to be diluted. When tolvaptan therapy brings the serum sodium level to normal levels, it must be discontinued to prevent hypernatremia. A serum sodium of 140 mEq/L is within the normal range.

After administering corticotropin, what assessments are priorities for the nurse? (Select all that apply.) A. Serum sodium levels B. Intake and output C. Acid and alkaline phosphatase levels D. C-reactive protein levels E. Changes in vision F. Glucose levels

A. Serum sodium levels B. Intake and output E. Changes in vision F. Glucose levels Rationale: Corticotropin can cause cataracts and glaucoma, so the nurse needs to monitor for changes in vision. Corticotropin stimulates the release of adrenal hormones, which can lead to sodium and fluid retention as well as hyperglycemia. Corticotropin can cause sodium and fluid retention, so that intake and output should be monitored. Serum sodium levels should be monitored, as sodium retention can be a result of corticotropin administration. C-reactive protein, acid and alkaline phosphatase levels are not indicated for monitoring.

Which assessment finding of a client 8 hours after a subtotal thyroidectomy does the nurse consider most relevant as an indication of a possible complication? A. The client's hand spasms during blood pressure measurement. B. The respiratory rate has dropped from 18 to 14 breaths per minute. C. The dressing has a moderate amount of serosanguinous drainage. D. The client responds to questions correctly but does not open the eyes while talking.

A. The client's hand spasms during blood pressure measurement. Rationale: Hand spasms in the presence of decreased oxygen (as would happen while a blood pressure cuff was inflated above systolic pressure) is an indication of hypocalcemia, a possible complication of reduced parathyroid function that can result from thyroid surgery. The respiratory rate is within normal limits for a healthy adult. A moderate amount of drainage may be more than expected but is not an indication of obstruction. After general anesthesia, most clients are sleepy. Not opening his or her eyes during a response to a question is not an indication of a complication.

Which assessment finding in a client with diagnosis of diabetes insipidus (DI) indicates to the nurse that desmopressin therapy is effective? A. Urine output of 30 to 50 mL/hr B. Blood glucose level of 110 mg/dL (6.1 mmol/L) C. Respiratory rate of 20 breaths/min D. Potassium level of 3.9 mEq/L (mmol/L)

A. Urine output of 30 to 50 mL/hr Rationale: With DI, insufficient amounts of vasopressin (antidiuretic hormone [ADH]) prevent reabsorption of water, leading to profound diuresis that can result in dehydration. Desmopressin, a synthetic form of ADH, is the drug of choice to stop fluid loss.A blood glucose result of 110 mg/dL (6.1 mmol/L) is within the range of normal blood glucose levels, as are the respiratory rate and the potassium level.

Which electrolyte laboratory result for a presurgical client will the nurse report to the anesthesiologist? (Select all that apply.) A. White blood cell count 14,000 mm3 B. Potassium, 3.9 mEq/L (3.9 mmol/L) C. Creatinine, 1.9 mg/dL (168 mcmol/L) D. Fasting glucose, 80 mg/dL (4.4 mmol/L) E. Sodium, 140 mEq/L (140 mmol/L)

A. White blood cell count 14,000 mm3 C. Creatinine, 1.9 mg/dL (168 mcmol/L) Rationale: The nurse will report a creatinine of 1.9 mg/dL (168 mcmol/L) and a white blood cell count of 14,000 mm3 to the anesthesiologist. These values are outside of the expected normal ranges and may indicate renal problems (creatinine) and infection (white blood cell count).

Which of the following are the priority precautions the nurse will teach the client who remains at continuing risk for adrenal hypofunction and is taking hormone replacement therapy to prevent harm related to the disorder? Select all that apply. A. Avoid crowds and people who are ill B. Check your heart rate for irregular or skipped beats twice daily C. Do not choose low sodium versions of prepared foods D. Get up slowly from sitting or lying positions E. Keep a source of glucose, such as candy, with you at all times F. Never skip your hormone replacement drugs

Answers: A, B, C, D, E, F All precautions are a priority. The hormone replacement therapy reduces inflammation and Immunity, increasing the risk for infection. A pathologic problem with adrenal hypofunction and reduced aldosterone is increased serum potassium levels that cause cardiac dysrhythmias. Adrenal hypofunction causes low sodium levels, and the client needs to ensure an adequate intake of this mineral. The disorder is associated with hypotension and postural hypotension. Another common problem is hypoglycemia. The client should always have a concentrated oral glucose source on hand and eat it whenever symptoms of hypoglycemia are present. Skipping hormone replacement therapy increases the likelihood that serious and potentially life-threatening complications can occur quickly. Blood hormone levels need to be relatively constant.

The nurse is caring for a postoperative patient who has asked for pain medicine an hour before it is due. What is the priority nursing response? A. "You cannot have more pain medicine until an hour from now." B. "Can you describe the pain you are having, and rate it on a 1-10 scale?" C. "I can help you begin a pain diary so we can see trends when your pain worsens." D. "Let's try some relaxation exercises to help address the discomfort you are feeling."

B. "Can you describe the pain you are having, and rate it on a 1-10 scale?" Rationale: The nurse will assess the client's level of pain to determine whether it is increasing, unmanaged, or able to be managed until the next dose of medication is due. Telling the client they cannot have medication for another hour, without conducting an assessment, is inappropriate, as cues to a changing health status could be missed. Starting a pain diary may be an appropriate intervention at a later time, but does not address the client's immediate concern. Providing relaxation exercises may be appropriate, but only after an assessment is conducted to determine the cause of the client's pain.

Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes to prevent harm? A. "Check your hands and feet weekly for chronic excessive sweating." B. "Change positions slowly when moving from sitting to standing." C. "Avoid drinking caffeine or caffeinated beverages." D. "Be sure to take your blood pressure drug daily."

B. "Change positions slowly when moving from sitting to standing." Rationale: Cardiovascular autonomic neuropathy (CAN) affects sympathetic and parasympathetic nerves of the heart and blood vessels. This problem contributes to left ventricular dysfunction, painless myocardial infarction, and exercise intolerance. Most often, CAN leads to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing). These problems are from failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. As a result, blood flow to the brain is interrupted briefly. Orthostatic hypotension and syncope increase the risk for falls, especially among older adults.

A patient asks the nurse to explain the action of glucocorticoids. Which statement is the nurse's best response? A. "Glucocorticoids stimulate defense mechanisms to produce immunity." B. "Glucocorticoids influence carbohydrate, lipid, and protein metabolism." C. "Glucocorticoids decrease serum sodium and glucose levels." D. "Glucocorticoids are produced in decreased amounts during times of stress."

B. "Glucocorticoids influence carbohydrate, lipid, and protein metabolism." Rationale: Glucocorticoids play a major role in carbohydrate, lipid, and protein metabolism within the body. They are produced in increasing amounts during stress. They increase sodium and glucose levels and suppress the immune system.

Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply. A. "Avoid all dietary carbohydrate and fat." B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols." D. "Be sure to take your antidiabetes drug right before you engage in any type of exercise." E. "Keep your feet warm in cold weather by using either a hot water bottle or a heating pad." F. "Avoid foot damage from shoe-rubbing by going barefoot or wearing "flip-flops" when you are at home."

B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols." Rationale: Regardless of whether diabetes is type 1 or type 2, the long-term complications are the same as are most prevention activities. The microvascular complications of diabetes increase the risk for eye and vision problems for all who have the disorder. Annual examinations by an ophthalmologist are critical to preventing or delaying reduced vision. Hypercholesterolemia is common in diabetes and contributes to hypertension, as well as microvascular and macrovascular complications, especially cardiovascular problems. Reducing animal-sourced fats and using plant-based sterols is recommended for everyone. Controlling carbohydrate and fat intake is important but they cannot be avoided or eliminated from the diet. Exercising increases the risk for hypoglycemia. Taking antidiabetes drugs immediately before exercising increases this risk and should not be done. Most patients with diabetes, even type 2 diabetes, have some degree of peripheral neuropathy and an increased risk for development of foot ulcers and the need for amputation. Using hot water bottles and heating pads on the feet should never be done because the reduced sensory perception does not allow the client to know when feet are being damaged by the heat. Adults with diabetes should never walk bare-foot or just use "flip-flops" even in the home. They need to wear properly fitting shoes with sturdy soles to prevent any foot injury.

Which statement made by the client alerts the nurse to the possibility of hypothyroidism? A. "I seem to feel the heat more than other people." B. "I am always tired, even when I get 10 or 12 hours of sleep." C. "Food just doesn't taste good without a lot of salt." D. "My grandmother had thyroid problems."

B. "I am always tired, even when I get 10 or 12 hours of sleep." Rationale: Clients with hypothyroidism usually feel tired or weak and often report an increase in time spent sleeping, sometimes up to 14 to 16 hours per day. Thyroid problems are very common among women and do not demonstrate a specific pattern of inheritance.

During a preoperative assessment, which statement by a client requires further investigation by the nurse to assess surgical risks? A. "I quit smoking 10 years ago." B. "I had a heart attack 4 months ago." C. "I take a multivitamin daily." D. "I drink a glass of wine a night."

B. "I had a heart attack 4 months ago." Rationale: The statement by the client that he or she had a heart attack 4 months ago requires further investigation. Cardiac problems increase surgical risks, and the risk for a myocardial infarction during surgery is higher in clients who have heart problems.

Which statement made by the client who is going home after a transsphenoidal hypophysectomy indicates to the nurse correct understanding of actions to prevent complications from this treatment? A. "While I am awake, I will be sure to cough and deep breathe at least every 2 hours." B. "I will keep the cat food bowl on my counter so that I do not have to bend over." C. "Whenever I am out-of-doors in the sunshine, I will wear dark glasses." D. "If the dressing gets wet, I will wash the incision line and redress it immediately."

B. "I will keep the cat food bowl on my counter so that I do not have to bend over." Rationale: After this surgery, the client must take care to avoid activities that can increase intracranial pressure. They should avoid bending from the waste and should not bear down, cough, or lay flat. Wearing dark glasses while outside is not necessary to prevent complications from the surgery.

The nurse is instructing a client about the postoperative use of antiembolism stockings. Which statement by the client indicates the need for further teaching? (Select all that apply.) A. "I will take off my stockings one to three times a day for 30 minutes." B. "It is up to me to determine how long I wear the stockings at each interval." C. "My stockings are loose so they do not hurt my legs." D. "These stockings help promote blood flow." E. "I feel like these stockings are compressing my legs just a bit."

B. "It is up to me to determine how long I wear the stockings at each interval." C. "My stockings are loose so they do not hurt my legs." Rationale: Stockings that are too loose are ineffective. Stockings that are too tight will impede blood flow. The client should wear the stockings as prescribed; not at their own discretion. Frequent removal of the stockings is appropriate to allow for hygiene and a break from their wear. Antiembolism stockings may be used during and after surgery to promote venous return. Antiembolism stockings should fit properly by providing gentle compression to achieve the desired result.

What is the nurse's best response when a client, who has been taking high-dose corticosteroid therapy for a month for a problem that has now resolved, asks you why she needs to continue taking the corticosteroid? A. "Corticosteroids are a type of hormone, and once you have been started on a replacement hormone, you must continue the hormone replacement therapy for the rest of your life." B. "The drug suppressed your own adrenal gland secretion of corticosteroids. Slowly decreasing the dose over time allows your adrenal glands to start adequate secretion again." C. "It is possible for your health problem to recur when corticosteroid therapy is halted suddenly." D. "The drug suppressed your immune system while you were taking it. Slowly decreasing the dose over time prevents your immune system from starting up too quickly and causing allergic reactions."

B. "The drug suppressed your own adrenal gland secretion of corticosteroids. Slowly decreasing the dose over time allows your adrenal glands to start adequate secretion again." Rationale: One of the most frequent causes of adrenal insufficiency, a life-threatening problem, is the sudden cessation of long-term, high-dose corticosteroid therapy. This therapy suppresses the hypothalamic-pituitary-adrenal axis and must be withdrawn gradually to allow for pituitary production of ACTH and adrenal production of cortisol. None of the other statements are completely accurate.

A client with diabetes who now has chronic albuminuria asks the nurse how this change will affect his health. How will the nurse answer this question? A. "You will need to limit your intake of dietary albumin and other proteins to reduce the albuminuria." B. "This change indicates beginning kidney problems and requires good blood glucose control to prevent more damage." C. "Your risk for developing urinary tract infections is greatly increased, requiring the need to take daily antibiotics for prevention." D. "From now on you will need to keep your fluid intake to just 1 L daily and completely avoid caffeine to protect your kidneys."

B. "This change indicates beginning kidney problems and requires good blood glucose control to prevent more damage." Rationale: The microvascular complications of diabetes reduce kidney perfusion and damage the glomeruli, leading to chronic kidney disease. The first indication of this problem is chronic albuminuria from increased filtration of proteins through damage glomeruli. Although this problem cannot be reversed, the rate of progression can be slowed with tight glycemic control. With albuminuria, proteins are lost from the body and do need to be replaced, not restricted, at this stage. The risk for urinary tract infections is increased with glucose in the urine, not albumin or other protein. Reducing fluid intake has the potential to damage the kidneys further and is not helpful.

What is the nurse's best response when a client with Cushing syndrome screams at her husband, bursts into tears, throws her water pitcher against the wall, and then says "I feel like I am going crazy"? A. "You must learn to control your behavior. Because you are disturbing others, I am going to keep the door to your room closed and restrict your visitors." B. "You feel this way because of your high hormone levels. Your health care provider can prescribe an antianxiety drug for you." C. "I will tell your primary health care provider order a psychiatric consult for you." D. "You are probably feeling this way because you are frightened about having a chronic disease. Would you like some information about a support group?"

B. "You feel this way because of your high hormone levels. Your health care provider can prescribe an antianxiety drug for you." Rationale: Changes in blood cortisol levels can cause the client to show neurotic or psychotic behaviors. The client's need to know that these behavior changes do not reflect a true psychiatric disorder and will resolve when therapy results in lower and more steady blood cortisol levels. Drug therapy to reduce these feelings and behaviors may be appropriate.

For which client will the nurse question the prescription for long-term androgen therapy? A. A 40 year old who also has syndrome of inappropriate antidiuretic hormone (SIADH). B. A 52 year old with a history of prostate cancer treatment. C. A 30 year old who is taking antiviral therapy for HIV disease. D. A 66 year old with impotence that is resistant to standard erectile dysfunction therapy.

B. A 52 year old with a history of prostate cancer treatment. Rationale: Androgen therapy can make any residual prostate cancer cells proliferate and cause a recurrence of the disease.

Which client situation reflects the health care system of managed care? A. Client obtains vaccinations at a local community health center that is close to home. B. A client receives an annual physical where the cost has been predetermined as $80. C. A client sees a designed family physician who coordinates all aspects of the client's care. D. A client with abdominal pain is admitted to a hospital for 24 hours of observation.

B. A client receives an annual physical where the cost has been predetermined as $80. Rationale: Managed care is a type of organized delivery of care where costs have been determined by the managed care company and health care providers. Therefore, the client whose fixed cost for a physical at $80 is being treated via managed care.

A patient has been admitted after overdosing on acetaminophen. The nurse plans to monitor this patient for development of which complication related to the overdose? A. Kidney stones B. Acute hepatic necrosis C. Metabolic alkalosis D. Decreased urinary output

B. Acute hepatic necrosis Rationale: Acetaminophen in large doses is extremely hepatotoxic. Patients with normal hepatic function should receive no more than 4000 mg/day. An overdosage of acetaminophen should not result in decreased urinary output, kidney stones, or metabolic alkalosis.

The surgery for a client scheduled for an 8:00 AM procedure is delayed until 11:00 AM. What is the appropriate nursing action regarding administration of preoperative prophylactic antibiotic? A. Administer at 8:00 AM as originally prescribed. B. Adjust the administration time to be given at 10:00 AM. C. Do not administer, as preoperative prophylactic antibiotics are optional. D. Hold the antibiotic until immediately following surgery, and then administer.

B. Adjust the administration time to be given at 10:00 AM. Rationale: According to the Surgical Care Improvement Project (SCIP) guidelines, prophylactic antibiotics should be given within one hour before the surgical incision.

Clients who have deficiencies of which hormones will the nurse assess for increased risk of life-threatening consequences? A. Prolactin and prolactin inhibiting hormone (PIH) B. Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH) C. Growth hormone (GH) and melanocyte-stimulating hormone (MSH) D. Follicle-stimulating hormone (FSH) and luteinizing hormone (LH)

B. Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH) Rationale: Deficiencies of (ACTH) or TSH are the most life threatening because they cause a decrease in the secretion of vital hormones from the adrenal and thyroid glands.

Which instruction/precaution does the nurse teach a client to prevent harm during a 24-hour urine specimen collection? A. Be sure to keep the specimen cool for the entire collection period. B. Avoid splashing urine in the container when a preservative is present. C. Add the preservative to the collection container before adding any urine. D. Discard the first specimen that marks the beginning of the 24-hour test period.

B. Avoid splashing urine in the container when a preservative is present. Rationale: All instructions/precautions are needed for correct collection of a 24-hour urine collection. The only precaution that will prevent harm is the one for avoiding the splashing of any urine in the container with the preservative.

Which assessment findings in a client with hyperthyroidism indicates to the nurse that the client is in danger of thyroid storm? Select all that apply. A. Increased salivation B. Client report of increased palmar sweating C. Decreased pulse pressure from 40 mm Hg to 36 mm Hg D. Diminished bowel sounds in all four abdominal quadrants E. An increase in temperature from 99.5o F (37.5o C) to 101.3o F (38.5o C) F. Serum sodium level increase from 136 mEq/L (mmol/L) to 139 mEq/L (mmol/L) G. Increase in premature ventricular heart contractions from 4 per minute to 28 per minute

B. Client report of increased palmar sweating E. An increase in temperature from 99.5o F (37.5o C) to 101.3o F (38.5o C) G. Increase in premature ventricular heart contractions from 4 per minute to 28 per minute Rationale: The changes most associated with impending thyroid storm (thyroid crisis) are the increase in sweating, body temperature, and irregular heartbeats. This client requires immediate attention. Increased salivation and diminished bowel sounds are not associated with thyroid storm. The changes in pulse pressure and serum sodium values are still within normal limits and not insignificant.

Which assessment finding in a client with hyperaldosteronism indicates to the nurse that the condition is becoming more severe? A. Urine output for the past 24 hours has increased. B. Client reports numbness and tingling around the mouth. C. Temperature is now elevated. D. pH is now 7.43.

B. Client reports numbness and tingling around the mouth. Rationale: Hyperaldosteronism causes potassium to be excreted excessively. As hypokalemia becomes more severe, paresthesias occur with numbness and tingling around the mouth and of the fingers and toes.

Which hormones help prevent hypoglycemia? Select all that apply. A. Aldosterone B. Cortisol C. Epinephrine D. Growth hormone E. Glucagon F. Insulin G. Norepinephrine H. Proinsulin

B. Cortisol C. Epinephrine D. Growth hormone E. Glucagon G. Norepinephrine Rationale: Cortisol decreases glucose uptake by cells and increases liver production and release of glucose. Epinephrine and norepinephrine rapidly increase liver glycogen breakdown and release of glucose into circulation. Growth hormone also rapidly increases liver glycogen breakdown and increases release of glucose into circulation. Glucagon is the major hormone preventing hypoglycemia. It is produced and secreted by alpha cells of the pancreatic islets as soon as blood glucose levels begin to drop below normal. Aldosterone is an adrenal hormone that affects water and mineral metabolism, not glucose metabolism. Insulin decreases blood glucose levels and can cause hypoglycemia. Proinsulin is an inactive compound that does not directly affect blood glucose levels until it is metabolized into insulin.

Which action does the nurse implement for a client with wound evisceration? A. Irrigate the wound with warm, sterile saline. B. Cover the wound with a sterile, warm, moist dressing. C. Replace tissue protruding into the opening. D. Apply direct pressure to the wound.

B. Cover the wound with a sterile, warm, moist dressing. Rationale: Covering the wound with a sterile, warm, moist dressing protects the organs until the surgeon can repair the wound. Evisceration occurs when a wound opens up and body organs are exposed.

Which nursing action reflects systems thinking? A. Giving report to the next shift including client status B. Developing a quality improvement initiative for respiratory assessment C. Documenting the client's lung sounds each shift D. Reviewing best practice for respiratory assessment

B. Developing a quality improvement initiative for respiratory assessment. Rationale: The goal of systems thinking is to encourage the nurse to develop awareness of the interrelationships that exist between individual care and the overall context of health care safety and quality improvement. Documenting and reporting affect individual patient care. Reviewing best practice reflects improving individual nurse practice. Quality improvement initiatives address the systems level, working to improve assessment within an entire unit and/or facility.

A nurse is providing teaching for a patient who has to administer a mixed insuling dose of 30 units regular insulin and 70 units NPH insulin. Which technique is most appropriate for the nurse to include in patient teaching? A. Administer these insulins at least 10 min apart, so that you will know when they are working. B. Draw up the regular insulin into the syringe first, followed by the cloudy NPH insulin. C. Use the Z-track method for administration. D. Draw the medication into two separate syringes but inject into the same spot.

B. Draw up the regular insulin into the syringe first, followed by the cloudy NPH insulin. Rationale: Drawing up the regular insulin into the syringe first prevents accidental mixture of NPH insulin into the vial of regular insulin, which could cause an alteration in the onset of action of the regular insulin. The medications do not have to be in separate syringes and can be administered together. Z-track is an IM technique.

What is the nurse's best action when finding that a client who has had diabetes for 15 years has decreased sensory perception in both feet? A. Testing the sensory perception of the client's hands B. Examining both feet for indications of injury C. Explaining to the client that peripheral neuropathy is now present D. Documenting the finding as the only action

B. Examining both feet for indications of injury Rationale: When reduced peripheral sensory perception is present, the likelihood of injury is high. Any open area or other problem on the foot of a person with diabetes is at great risk for infection and must be managed carefully and quickly. Checking for sensory perception on the hands and other areas is important but can come after a thorough foot examination.

While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, slightly confused, and can still swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm? A. Call the pharmacy and order a STAT does of glucagon B. Immediately give the client 30 grams of glucose orally C. Start an IV and administer 50 mL of a 50% dextrose solution D. Recheck the blood glucose level and call the rapid response team

B. Immediately give the client 30 grams of glucose orally Rationale: The client's blood glucose level is seriously low and will get even lower quickly. Because the client can still swallow, giving 30 grams of glucose (following the 15-15 rule) is the best course of action. Obtaining a dose of glucagon from the pharmacy or starting an IV are too slow to prevent severe hypoglycemia. Just rechecking the blood glucose level without giving glucose is very dangerous when the client already has symptoms of hypoglycemia.

What is the nurse's best response when a client with diabetes who is being treated for hypoglycemic asks why people without diabetes don't become severely hypoglycemic even after fasting for 8 hours? A. In a person without diabetes, fasting for 8 hours converts proteins into glycose (gluconeogenesis) so that hypergycemia develops rather than hypoglycemia. B. In a person without diabetes, the secretion of glucagon prevents hypoglycemia by promoting glucose release from liver storage sites (glycogenolysis). C. Normal metabolism is so slow when a person without diabetes fasts that blood glucose does not enter cells to be used for energy. As a result, hypoglycemia does not occur. D. Lipolysis (fat breakdown) in fat stores occurs faster in the nondiabetic person, which converts fatty acids into glucose to maintain blood glucose levels.

B. In a person without diabetes, the secretion of glucagon prevents hypoglycemia by promoting glucose release from liver storage sites (glycogenolysis). Rationale: Glucagon is a counter-regulatory hormone secreted by pancreatic alpha cells when blood glucose levels are low, as they would be during an 8 hour fast. The body's metabolic rate does decrease during sleep (which is not stated in this question) but not sufficiently to prevent hypoglycemia. Glucagon works on the glycogen stored in the liver, breaking it down to glucose (glycogenolysis) molecules that are then released into the blood to maintain blood glucose levels and prevent hypoglycemia.

What effect on circulating levels of sodium and glucose does the nurse expect in a client who has been taking an oral cortisol preparation for 2 years because of a respiratory problem? A. Decreased sodium; decreased glucose B. Increased sodium; increased glucose C. Increased sodium; decreased glucose D. Decreased sodium; increased glucose

B. Increased sodium; increased glucose Rationale: Any of the glucocorticoids have some mineralocorticoid activity and increase the reabsorption of sodium from the kidney tubules, thus increasing the serum sodium level. Cortisol also increases liver production of glucose (gluconeogenesis) and inhibits peripheral glucose uptake by the cells. Both these actions increase blood glucose levels.

Which statements regarding hyperthyroidism are accurate? (Select all that apply.) A. Has a sudden onset of symptoms. B. Is much more common among women than among men. C. Produces symptoms of a hypermetabolic state. D. Most common form is Graves disease. E. Can be diagnosed by the presence of a goiter. F. Often occurs weeks after exposure to ionizing radiation.

B. Is much more common among women than among men. C. Produces symptoms of a hypermetabolic state. D. Most common form is Graves disease. Rationale: Hyperthyroidism increases the metabolism and function of all systems. The most common cause of hyperthyroidism is Graves disease, which is an autoimmune disorder, often occurring after an episode of thyroid inflammation leading to the production of autoantibodies (thyroid-stimulating immunoglobulins [TSIs]) that attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid gland. The increased stimulation of TSH receptors greatly increases thyroid hormone production. All thyroid problems are from five to ten more common among women than men.

In collaboration with the registered dietitian nutritionist, which dietary alterations will the nurse instruct a client with Cushing disease to make? A. High carbohydrate, low potassium, and fluid restriction B. Low carbohydrate, high calorie, and low sodium C. Low protein, high carbohydrate, and low calcium D. High protein, high carbohydrate, and low potassium

B. Low carbohydrate, high calorie, and low sodium Rationale: The client with Cushing disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of total calories and carbohydrates to prevent or reduce the degree of hyperglycemia. The sodium retention causes water retention and hypertension. Clients are encouraged to moderately restrict sodium intake.

Which signs, symptoms, or behaviors will the nurse expect to find when assessing a client who has just been diagnosed with hypothyroidism? (Select all that apply.) A. Goiter B. Nonpitting edema of hands and feet C. Warm, moist skin D. Decreased deep tendon reflexes E. Agitation and inability to sleep F. Pulse rate below 60 beats/min

B. Nonpitting edema of hands and feet D. Decreased deep tendon reflexes F. Pulse rate below 60 beats/min Rationale: Hypothyroidism slows the metabolism and function of all systems and the ones that are usually first noticed and can lead to life-threatening complications are the cardiac and central nervous systems. Thus, the heart rate is usually slower than 60 beats/min, and the deep tendon reflexes are decreased. Metabolites that are compounds of proteins and sugars called glycosaminoglycans (GAGs) build up inside cells, which increase the mucus and water, forming cellular edema that is nonpitting.

Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal insufficiency undergoing IV therapy with hydrocotisone that the client is responding positively to this drug therapy? A. Serum sodium 147 mEq/L (mmol/L); serum potassium 7.1 mEq/L (mmol/L) B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L) C. Serum sodium 127 mEq/L (mmol/L); serum potassium 2.8 mEq/L (mmol/L) D. Serum sodium 119 mEq/L ((mmol/L); serum potassium 6.2 mEq/L (mmol/L)

B. Serum sodium 137 mEq/L (mmol/L); serum potassium 4.9 mEq/L (mmol/L) Rationale: With adrenal hypofunction reduced levels of cortisol and aldosterone decrease serum sodium levels below normal (hyponatremia) and increase serum potassium levels above normal (hyperkalemia). Adequate drug therapy with hormone replacement is expected to return these electrolytes back to their normal ranges (sodium = 135-145 mEq/L [mmol/L]; potassium = 3.5-5.0 mEq/L [mmol/L]). Response A indicates hypernatremia and hyperkalemia. Response C indicates hyponatremia and hypokalemia. Response D indicates severe hyponatremia and hyperkalemia.

The nurse completes the preoperative checklist for a client scheduled for general surgery. Which factor does the nurse identify that places the client at high risk for the planned procedure? (Select all that apply.) A. Ten pounds (4.5 kg) over ideal body weight B. Takes saw palmetto for benign prostatic hyperplasia (BPH) C. Anesthesia complications experienced by partner D. Currently prescribed methylprednisolone therapy E. Age 59 years F. History of diabetes mellitus

B. Takes saw palmetto for benign prostatic hyperplasia (BPH) D. Currently prescribed methylprednisolone therapy F. History of diabetes mellitus Rationale: The client's risk factors include diabetes mellitus, being on methylprednisolone therapy, and taking an herbal preparation (saw palmetto). Diabetes contributes an increased risk for surgery or postsurgical complications. Methylprednisolone use can decrease the body's ability to fight infection. Any type of herbal preparation has the potential to interfere with anesthesia or recovery.

Which assessment finding in a 40-year-old client is most relevant for the nurse to assess further for a possible endocrine problem? A. He has lost 10 lbs in the past month following a low carbohydrate eating plan. B. The client reports now only needed to shave once weekly instead of daily. C. His new prescription for eye glasses is for a higher strength. D. The client's father died of a stroke at age 70 years.

B. The client reports now only needing to shave once weekly instead of daily. Rationale: A change in degree of facial hair is could indicate an endocrine problem, particularly of the pathway for testicular function. An intentional weight loss of 10 lb over a month's time is within the normal range for gender and age. Although the need for a stronger prescription for eye glasses at this age could potentially be related to an endocrine problem, many other factors are more likely to be related to this problem. The same is true of his father's stroke.

The nurse is teaching a class on systems thinking in nursing. What teaching will the nurse include? (Select all that apply.) A. Systems thinking is not affected by health policy at the national level. B. The complexity of client care can affect systems thinking. C. Systems thinking shifts the focus from safety to quality in care. D. It is important for the nurse to place all focus on individualized client care. E. Systems thinking allows the nurse to assess the root of problems. F. Interprofessional, collaborative care is fostered when using systems thinking.

B. The complexity of client care can affect systems thinking. E. Systems thinking allows the nurse to assess the root of problems. F. Interprofessional, collaborative care is fostered when using systems thinking. Rationale: Systems thinking pushes the nurse to look beyond the individualized client to consider the impacts within the health care system as a whole. Systems thinking does allow the nurse to consider the root problems that affect care and fosters interprofessional care. Systems thinking does not shift away from safety, rather it promotes safety through quality-based care. The complexity of care and health policy as local, state, national, and global levels can affect systems thinking.

Why is a goiter often present in clients who have Graves disease? A. The low circulating levels of thyroid hormones stimulates the feedback system and triggers the anterior pituitary gland to secrete more thyroid-stimulating hormone, which increases the numbers and size of glandular cells in the thyroid gland. B. The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland. C. The autoantibodies stimulate blood vessel growth and blood storage within the thyroid gland, increasing its overall size. D. The autoantibodies stimulate the inflammatory and immune responses to increase the number of white blood cells circulating in the thyroid gland, which increases tissue size without increasing the number of glandular cells.

B. The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland. Rationale: Graves disease is an autoimmune disorder in which antibodies (thyroid-stimulating immunoglobulins [TSIs]) are made and attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid tissue. The thyroid gland responds by increasing the number and size of glandular cells, which enlarges the gland, forming a goiter and overproduces thyroid hormones (thyrotoxicosis).

How will the nurse evaluate the level of glycemic control for a client with diabetes whose laboratory values include a fasting blood glucose level of 82 mg/dL (mmol/L) and an A1c of 5.9%? A. The values indicate that the client has poorly managed his or her disease. B. The values indicate that the client has managed his or her disease well. C. The client's glucose control for the past 24 hours has been good but the overall control is poor. D. The client's glucose control for the past 24 hours has been poor but the overall control is good.

B. The values indicate that the client has managed his or her disease well. Rationale: Fasting blood glucose levels provide an indication of the client's adherence to drug and nutrition therapy for DM has been for the previous 24 hours. This client's FBG is well within the normal range.

The nurse is caring for several patients who will be receiving glucocorticoid therapy. Which patient should be assessed first based on clinical diagnosis? A. Recovering from septic shock B. Uncontrolled diabetes mellitus C. Chronic rheumatoid arthritis D. Exacerbation of asthma controlled using oxygen therapy.

B. Uncontrolled diabetes mellitus Rationale: A common side effect of steroid therapy is hyperglycemia. The patient with uncontrolled diabetes mellitus could suffer a severe hyperglycemic episode. The other clinical diagnoses presented do not required immediate action.

How will the nurse modify insulin injection technique for a client who is 5 feet 10 inches tall and weighs 106 lb (48.1 kg) A. Use a 6 mm needle and inject at a 90-degree angle. B. Use a 6 mm needle and inject at a 45-degree angle. C. Use a 12 mm needle and inject at a 90-degree angle. D. Use a 12 mm needle and inject at a 45-degree angle.

B. Use a 6 mm needle and inject at a 45-degree angle. Rationale: The client is very thin. Using either a longer needle or injecting the insulin at a 90-degree angle increases the likelihood of performing an intramuscular injection instead of a subcutaneous one, which would affect insulin absorption. Selecting a shorter needle and injecting at a 45-degree angle prevents an intramuscular injection into this client.

A client newly diagnosed with type 1 diabetes says she is not ready to learn everything about diabetes control right now. Which information has the greatest priority for the nurse to teach this client and her family for now to prevent harm? (Select all that apply.) Select all that apply. A. Causes of type 1 diabetes B. What to do when ill? C. Symptoms and treatment of hypoglycemia D. Insulin administration E. Dietary control of blood glucose F. Importance of regular exercise

B. What to do when ill? C. Symptoms and treatment of hypoglycemia D. Insulin administration Rationale: The priority information for safety and preventing harm that the nurse needs to teach the client and family about diabetes are: Symptoms and management of hypoglycemia because it is a life-threatening condition. Proper insulin administration is essential for the management of type 1 diabetes and to prevent death. Knowing what to do when ill is critical information because illness will require changes in the client's day-to-day use of insulin and may need contact with the client's diabetes health care provider to prevent harm. The causes of diabetes, dietary control, and exercise are less important for immediate safety and can be taught at another time.

The nurse is providing preoperative care for a client who will have an arthroscopy of the left knee. As part of The Joint Commission National Patient Safety Goals (NPSG), what will the nurse do as the priority? A. Ensure that the correct procedure is noted in the client's health record. B. Witness marking of the left knee site with the client awake and the surgeon present. C. Communicate with the surgeon confirming the client will have a left knee arthroscopy. D. Verify with the client that a left knee arthroscopy will be performed.

B. Witness marking of the left knee site with the client awake and the surgeon present. Rationale: The nurse will be required to mark the left knee site with the client awake and the surgeon present. The Joint Commission NSPG requires that the surgical site be marked by an independent licensed professional and should, when possible, involve the client. The surgeon is accountable and should be present.

What is the nurse's best first response when a client with a suspected endocrine disorder says, "I can't, you know, satisfy my wife anymore."? A. "Don't worry. It happens to everyone occasionally." B. "Do you use any over the counter or recreational drugs?" C. "Can you please tell me more?" D. "Would you like to speak with a counselor?"

C. "Can you please tell me more?" Rationale: An open-ended question such as, "Can you please tell me more?," is a best first response because it allows the nurse to explore the client's feelings more thoroughly. Clients with endocrine disorders may report issues with infertility, impotence, and changes in sexual function.

Which precaution is most important for the nurse to teach a female client to prevent harm while undergoing drug therapy with estrogen and progesterone for hypopituitarism? A. "Use a barrier method of contraception to prevent an unplanned pregnancy." B. "Wear a hat with a brim and use sunscreen when outdoors." C. "Do not smoke or use nicotine in any form." D. "Avoid drinking caffeinated beverages."

C. "Do not smoke or use nicotine in any form." Both estrogen therapy and progesterone therapy increase the risk for thromboembolism formation. This condition greatly increases the chance for strokes, heart attacks, and pulmonary embolism. Cigarette smoking and other forms of nicotine increase this risk. Pregnancy is unlikely to occur without further medical intervention. These hormones do not increase photosensitivity or the general risk for harm from ultraviolet radiation exposure. There are no recommendations for avoiding caffeine while taking these drugs.

The nurse is caring for a client who reports being fearful of becoming dependent on opioid pain medication after surgery. What is the appropriate nursing response? Select all that apply. A. "Why do you think you're going to get hooked?" B. "Don't worry, I won't give you any opioid medications." C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent."

C. "Have you had concerns with drug dependence in the past?" D. "Tell me what makes you most fearful about taking opioid medication." E. "There are proper ways of taking opioids so you will not become dependent." Rationale: The nurse will use therapeutic communication to determine the client's underlying concerns. This is accomplished by asking the client if there has been a past history of drug dependence (which may explain the reluctance), what seems most fearful about taking opioids (which gives the nurse the chance to dispel myths), and teaching that there are proper ways of taking opioids (as directed and for a short period of time) that is meant to keep the client from becoming dependent. Asking "why" is nontherapeutic and can shut down the line of communication between the client and nurse, as this approach demands a response. The nurse will not promise to give the patient opioids at this time, as further investigation of the client's concerns are warranted first.

The nurse is participating in a unit meeting to discuss daily nursing care expectations. Which nursing statement reflects systems level thinking? A. "It is important to provide care consistent with the client's expectation." B. "I will always consider my client's cultural preferences when delivering care." C. "I have been comparing our rates of infection with other units in the hospital." D. "I will look for the policy about family visitation to show my client."

C. "I have been comparing our rates of infection with other units in the hospital." Rationale: Comparing rates of infection with other units shows the nurse has moved beyond the individual level of care to consider how individual care creates an environment that can be compared with other environments. Although providing care consistent with the client's expectation, considering a client's cultural preference, and educating a client about family visitation are appropriate nursing actions, they address care at the individual - not the systems - level of thinking.

The nurse reviews a routine discharge teaching plan on postoperative care with a client. Which client statement indicates that teaching about wound care has been effective? A. "The wound will completely heal in about 2 months." B. "I should remove the dressing if the wound is draining." C. "I may need to restrict my activities for several months." D. "Some bleeding from the incision is normal for several weeks."

C. "I may need to restrict my activities for several months." Rationale: To protect the integrity of the wound, activities may need to be restricted.

What is the nurse's best response to a client newly diagnosed with type 1 diabetes who asks why insulin is only given by injection and not as an oral drug? A. "Injected insulin works faster than oral drugs to lower blood glucose levels." B. "Oral insulin is so weak that it would require very high dosages to be effective." C. "Insulin is a small protein that is destroyed in by stomach acids and intestinal enzymes." D. "Insulin is a "high alert drug" and could more easily be abused if it were available as an oral agent."

C. "Insulin is a small protein that is destroyed in by stomach acids and intestinal enzymes." Rationale: Because insulin is a small protein that is easily destroyed by stomach acids and intestinal enzymes, it cannot be used as an oral drug. Most commonly, it is injected subcutaneously.

Which statement made by a client who is undergoing therapy with radioactive iodine (RAI) for Graves disease indicates a lack of understanding about the disorder and its treatment? A. "Luckily, I have my own bathroom, so I won't be exposing the rest of my family to radiation. B. "If this treatment works, maybe I will stop sweating all the time. C. "It will be great to lose my "bug-eyed" appearance. D. "I hope I don't gain too much weight when my thyroid function is normal.

C. "It will be great to lose my "bug-eyed" appearance. Rationale: Although successful radioactive iodine (RAI) therapy for Graves disease results in reducing most physical symptoms, the exophthalmia does not respond to this therapy. Other measures, such as drug therapy targeted to the exophthalmos and not the hyperthyroidism and surgery to remove tissue from behind the eye, are needed to improve the eye appearance. All other client statements demonstrate accurate understanding of the disorder and its treatment.

The patient with type 1 diabetes mellitus asks, "Why can't I take a sulfonylurea like my friend who has diabetes?" What is the nurse's best response? A. "You are unable to store glucose, because you do not have insulin, and sulfonylurea helps with glucose storage." B. "Sulfonylurea will lower your blood sugar too much, and you will be hypoglycemic." C. "Sulfonylurea increases beta-cell stimulation to secrete insulin, and with your type of diabetes, the beta cells do not contain insulin. This medication will not work for you." D. "You must be mistaken. If your friend has diabetes mellitus, she is taking insulin."

C. "Sulfonylurea increases beta-cell stimulation to secrete insulin, and with your type of diabetes, the beta cells do not contain insulin. This medication will not work for you." Rationale: Sulfonylurea agents reduce serum glucose levels by increasing beta-cell stimulation for insulin release, decreasing hepatic glucose production, and increasing insulin sensitivity. It is administered for type 2 diabetes mellitus but will not be effective in type 1 as the beta cells are not functional.

A client at continuing risk for hyperparathyroidism is prescribed to take furosemide 40 mg and to drink at least 3 to 4 L of fluid daily. He tells the nurse he believes taking a "water pill" and then drinking so much seems wrong. How will the nurse respond? A. "This combination of a water pill and drinking more ensures protects you from buildup of excess sodium in the kidney." B. "The furosemide makes you lose water and you need to increase your intake to keep from becoming dehydrated." C. "The drug helps you to get rid of calcium and drinking more helps dilute your blood calcium so the level doesn't get too high." D. "You are correct. I will check with your primary health care provider to determine whether you should restrict your fluid intake."

C. "The drug helps you to get rid of calcium and drinking more helps dilute your blood calcium so the level doesn't get too high." Rationale: The purpose of the furosemide and hydration therapy is to lower the blood calcium levels to manage the hypercalcemia associated with hyperparathyroidism. Although it is true that increasing fluid intake while on furosemide can help prevent dehydration and also helps excrete sodium, that is not the desired outcome in hyperparathyroidism.

A patient receiving propylthiouracil (PTU) asks the nurse how this medication will help relieve symptoms. Which statement is the nurse's best response? A. "PTU inactivates any circulating thyroid hormone, thus decreasing signs and symptoms of hyperthyroidism." B. "PTU helps the thyroid gland use iodine and synthesize hormones better." C. "This medication inhibits the formation of new thyroid hormone, thus gradually returning your metabolism to normal." D. "This medication stimulates the pituitary gland to secrete thyroid-stimulating hormone, which inhibits the production of hormones by the thyroid gland."

C. "This medication inhibits the formation of new thyroid hormone, thus gradually returning your metabolism to normal." Rationale: Propylthiouracil (PTU) is an antithyroid medication used to treat hyperthyroidism. It works by inhibiting the synthesis of new thyroid hormone. It does not inactivate hormone already present.

What is the nurse's best response to a client with type 2 diabetes controlled with metformin who asks why now that he is recovering from surgery, is he prescribed to receive insulin therapy for a few days? A. "Your insurance doesn't permit metformin to be used during hospitalization." B. "Your presurgical testing indicates that you now have type 1 diabetes and require daily insulin." C. "You just need insulin temporarily because the stress of surgery causes increased blood glucose levels for a day or two." D. "You must take insulin from now on because the surgery has aggravated the intensity of your diabetes."

C. "You just need insulin temporarily because the stress of surgery causes increased blood glucose levels for a day or two." Rationale: The nurse's best response is that due to the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for clients with diabetes who use oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides.

When (at which time) will the nurse plan to monitor for hypoglycemia in a client with type 1 diabetes received regular insulin at 7:00 a.m.? A. 7:30 a.m. B. 7:30 p.m. C. 11:00 a.m. D. 2:00 p.m.

C. 11:00 a.m. Rationale: Regular insulin is a short-acting type of insulin. Onset of action to regular insulin is ½ to 1 hour. The peak effect time is when hypoglycemia may start to occur. Peak time for regular insulin is 2 to 4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m. The other options for peak times for regular insulin are incorrect.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 50 year old taking repaglinide who has nausea and back pain. B. A 55 year old taking pioglitazone who has bilateral ankle swelling. C. A 45 year old taking metformin who has abdominal cramps. D. A 40 year old taking glyburide who is dizzy and sweaty.

C. A 45 year old taking metformin who has abdominal cramps. Rationale: The nurse needs to first assess the client taking glyburide who is dizzy and sweaty and has symptoms consistent with hypoglycemia. Because hypoglycemia is the most serious adverse effect of antidiabetic medications, this client must be assessed as soon as possible. Nausea is a documented side effect of repaglinide. Checking the client's back pain requires assessment, which can be performed after the nurse assesses the client displaying signs and symptoms of hypoglycemia. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.

A nurse is providing discharge teaching for a patient receiving glucocorticoids. Which medication should the nurse expect to be included for pain management? A. Aspirin B. Ibuprofen C. Acetaminophen D. Naproxen sodium

C. Acetaminophen Rationale: Acetaminophen does not cause gastric distress as do aspirin, ibuprofen, naproxen sodium, and glucocorticoids.

Which assessment finding in a client who had a parathyroidectomy yesterday indicates to the nurse that immediate action is needed? A. Hypoactive bowel sounds B. Apical pulse of 92 beats/min C. Bilateral leg muscle twitching D. Dry mouth

C. Bilateral leg muscle twitching Rationale: Clients are at risk for hypocalcemia and seizures after removal of the parathyroid glands. Muscle twitching is an indication of hypocalcemia and requires assessment and intervention. The other findings are abnormal but not associated with complications from the surgery.

Which items are most important for the nurse to ensure are in the room when a client returns from having a thyroidectomy? (Select all that apply.) A. Hypertonic saline B. Furosemide C. Calcium gluconate D. Oxygen E. Suction F. Emergency tracheotomy kit

C. Calcium gluconate D. Oxygen E. Suction F. Emergency tracheotomy kit Rationale: Calcium gluconate needs to be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during the surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema occludes the airway. Oxygen always needs to be at the bedside and especially for the thyroidectomy client who may experience respiratory distress from swelling or damage to the laryngeal nerve leading to spasm. It is also important to have suction available at the client's bedside because of the risk for increased secretions.

The nurse is teaching a class on clinical judgment. What teaching will the nurse include? A. Clinical judgment is a fixed process. B. Clinical judgment is not required to make an informed decision. C. Clinical judgment is an outcome of critical thinking. D. Clinical judgment happens outside the context of the scenario.

C. Clinical judgment is an outcome of critical thinking. Rationale: Clinical judgment, as defined by the National Council of State Boards of Nursing, is the observed outcome of critical thinking and decision making. It is an iterative process (not fixed) that uses nursing knowledge to observe and access presenting situations, identify a prioritized client concern, and generate the best possible evidence-based solutions in order to deliver safe client care.

As the nurse gives a client the informed consent form to sign, the client asks, "Now what exactly are they going to do to me?" What is the appropriate nursing action? A. Have the client sign the form. B. Contact the anesthesiologist. C. Contact the surgeon. D. Explain the procedure.

C. Contact the surgeon. Rationale: The nurse will contact the surgeon to convey the client's question. The nurse is not responsible for explaining or providing detailed information about the surgical procedure. Rather, the nurse's role is to clarify facts that have been presented by the health care provider and dispel myths that the client or family may have heard about the surgical experience.

The nurse reviewing the laboratory values of a client with hypoparathyroidism finds a serum calcium level of 7.9 mg/dL (1.76 mmol/L). Which parameter is most important for the nurse to assess to prevent harm? A. Temperature B. Heart rate and rhythm C. Deep tendon reflexes D. Level of consciousness

C. Deep tendon reflexes The serum calcium is low, placing the client in danger of increased muscle contractions and tetany. The client's deep tendon reflexes should be evaluated for hyperreflexia, which is an indicator of impending tetany. The other parameters are much less affected by hypocalcemia.

Which nursing element reflects systems thinking at the global level of practice? A. Facility health policy B. Quality improvement initiative C. Determinants of health D. Interprofessional practice

C. Determinants of health Rationale: Systems thinking can exist globally, nationally, or locally. An example of global level systems thinking is the determinants of health as these are elements of health that are developed on a global level in relation to population health.

The nurse is caring for a client who is to undergo surgery at 6:00 AM today. Which assessment data will the nurse communicate immediately to the surgeon and anesthesia provider? Select all that apply. A. Blood pressure 130/72 B. Serum potassium 3.5 mEq/L C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday E. Has not had food nor water since 9:00 PM last night

C. Diffuse rash on upper torso D. Took 650 mg of aspirin yesterday Rationale: A diffuse rash could be an indication of a health deviation that must be assessed before surgery. Taking aspirin (or any other medication that anticoagulates) is generally not permitted for a certain period of time before surgery. Therefore, the nurse will notify the surgeon and anesthesia provide of both of these assessment findings. A blood pressure of 130/72 and a serum potassium of 3.5 mEq/L are normal findings, as is the adherence of the client who has not had food nor water for the recommended time before surgery.

Which precaution is a priority for the nurse to teach a client prescribed pramlintide to prevent harm? A. Only take this drug once weekly. B. Do not drink alcohol when taking this drug. C. Do not mix in the same syringe with insulin. D. Report any genital itching to your primary health care provider.

C. Do not mix in the same syringe with insulin. Rationale: Pramlintide is an amylin analog injected subcutaneously several times daily with or right before any meal. It has a pH that is different from and incompatible with insulin and is not to be mixed in the same syringe. It does not increase the risk for genital yeast infections. It does not increase the risk for lactic acidosis when alcohol is comsumed.

The nurse is providing patient teaching for the drug miglitol for the patient with a diagnosis of type 2 diabetes. Which group of side effects should the nurse include in the patient teaching? A. Dehydration, hypoglycemia, and thirst B. Rash, gingivitis, and hypoglycemia C. Flatulence, hypoglycemia, and diarrhea D. Hypoglycemia, diaphoresis, and hypokalemia

C. Flatulence, hypoglycemia, and diarrhea Rationale: Side effects of miglitol include flatulence, diarrhea, and abdominal pain.

Which type of drug therapy will the nurse prepare to teach about to a client who has mild hyperparathyroidism? A. Antipyretics B. Opioid analgesics C. Furosemide diuretics D. Calcium supplements

C. Furosemide diuretics Rationale: High ceiling or loop diuretics, such as furosemide increase calcium excretion and are used to manage calcium levels in clients who have mild hyperparathyroidism. Antipyretics are not routinely prescribed because fever is not associated with the disorder. Opioid analgesics are used only when a problem causing acute pain is present and not for typical management of mild hyperparathyroidism. Calcium supplements are contraindicated because hyperparathyroidism results in chronic hypercalcemia.

Which changes in laboratory values will the nurse expect to see in a client who has tumor causing excess secretion of aldosterone? (Select all that apply.) A. Hypoglycemia B. Hyponatremia C. Hypokalemia D. Hypernatremia E. Hyperglycemia F. Hyperkalemia

C. Hypokalemia D. Hypernatremia Rationale: Aldosterone is the mineralocorticoid that maintains extracellular fluid volume and electrolyte composition. It promotes sodium and water reabsorption and potassium excretion in the kidney. Excessive amounts of this hormone result in hypernatremia and hypokalemia.

Which nursing action reflects the QSEN competency of Patient-Centered Care? (Select all that apply.) A. Designing nursing care with a focus on keeping the client safe B. Participating on a committee that is evaluating the newest bar-code scanner C. Including the client in discussions about dietary choices D. Respecting the client's preference about treatment options E. Referring to a nursing journal to consider trends in care F. Using data collected over the past quarter to determine if and how nursing care should change

C. Including the client in discussions about dietary choices D. Respecting the client's preference about treatment options Rationale: The QSEN competency of Patient-Centered Care recognizes that the client, with his or her own autonomy, is at the center of all decision making related to care. Respecting the client's preferences about treatment, and including the client in discussions about dietary choices, reflects patient-centered care.

Which client assessment finding indicates to the nurse the possible presence of diabetic autonomic neuropathy? A. Loss of sensation in both feet B. Hyperglycemia C. Intermittent constipation D. Increased thirst

C. Intermittent constipation Rationale: Autonomic neuropathy can affect the entire GI system. The most common GI problem from diabetic automonic neuropathy is sluggish intestinal movement and chronic intermittent constipation.

The nurse is caring for a patient who has just started taking levothyroxine. What assessment finding is a priority for the nurse to address? A. Heart rate 55 beats/min B. Weight gain of 3 pounds in the last week C. Irritability D. Intolerance to cold

C. Irritability Rationale: Irritability is a symptom of hyperthyroidism. This could be a sign that the medication dose is too high. A lowered heart rate, weight gain, and intolerance to cold could be symptoms of hypothyroidism and are expected in this patient, who just began medication therapy.

The nurse administers NPH insulin at 8 AM. What intervention is essential for the nurse to perform? A. Administer the insulin via IV pump. B. Monitor fingerstick at 2 PM. C. Make sure patient eats by 5 PM. D. Assess the patient for hyperglycemia by 10 AM.

C. Make sure patient eats by 5 PM. Rationale: NPH insulin may be peaking just before dinner without sufficient glucose on hand to prevent hypoglycemia. The patient needs to eat by 5 PM. The patient would not be at high risk for hypoglycemia at 10 AM. A fingerstick is not necessary at 2 PM. The insulin should not be routinely administered via IV.

An assistive personnel reports that a nursing home client who has hypothyroidism has a pulse of 48 beats per minute this morning. Which assessments have the highest priority for the nurse to perform immediately? Select all that apply. A. Checking body temperature B. Testing deep tendon reflex responses C. Measuring oxygen saturation by pulse oximetry D. Checking blood pressure, heart rate, and rhythm E. Determining level of consciousness and cognition F. Identifying presence or absence of the swallowing reflex G. Examining feet and ankles for indications of peripheral edema

C. Measuring oxygen saturation by pulse oximetry D. Checking blood pressure, heart rate, and rhythm Rationale: with hypothyroidism whose metabolism is decreasing. However, the most common cause of death for a client with severe hypothyroidism is respiratory failure with reduced gas exchange and perfusion. Thus, measuring oxygen saturation should be performed first followed by assessment of cardiac function in order to implement the most effective interventions as soon as possible.

Which client symptom appearing after a head injury suffered in a car crash is most relevant for the nurse to consider the possibility of diabetes insipidus (DI)? A. New-onset hypertension. B. The client reports extreme salt craving. C. No change in urine output with minimal fluid intake. D. The client's headache is gradually increasing in intensity.

C. No change in urine output with minimal fluid intake. Rationale: DI results from absent or insufficient secretion of antidiuretic hormone (ADH, vasopressin) from the posterior pituitary and can result from a head injury that damages this endocrine gland. With less or absent ADH, the client is unable to reabsorb water even when fluid intake is low. Although headache is usually present with a head injury, it is not associated with DI. The dehydration associated with DI would cause hypotension and an increased serum sodium concentration.

Which action is appropriate for the nurse to delegate to the assistive personnel (AP) when caring for clients with diabetes? A. Monitoring a client who reports palpitations and anxiety B. Verifying the infusion rate on a continuous infusion insulin pump C. Performing a blood glucose check on a client who requires insulin D. Assessing a client who reports tremors and irritability

C. Performing a blood glucose check on a client who requires insulin Rationale: Performing bedside glucose monitoring is a task that may be delegated to an AP who has been educated in this technique because it does not require extensive clinical judgment to perform. There is no evidence the client is unstable at this time. The nurse will follow up with the results and insulin administration after assessing the less stable clients. Intravenous therapy and medication administration are not within the scope of practice for AP. The client with tremors and irritability is displaying symptoms of hypoglycemia requiring further assessment and intervention that are not within the scope of practice for AP. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention. This client must be assessed by licensed nursing staff.

Which assessment is a priority for the nurse to make when a client with diabetic ketoacidosis (DKA) who is being monitored while receiving an insulin infusion begins to show an irregular heart beat with inverted T-waves? A. Rate of IV infusion B. Urine output C. Potassium level D. Breath sounds

C. Potassium level Rationale: After DKA therapy starts, serum potassium levels drop quickly. An ECG showing an irregular pattern and inverted T-waves is most likely related to low potassium levels (hyperkalemia). Hypokalemia is a common cause of death in the treatment of DKA. Detecting and treating the underlying cause of the cardiac irregularities is essential. The cardiac issues are not associated with changes in urine output even though hyperglycemia will cause osmotic diuresis. The client with DKA is not at risk for hypoventilation or poor gas exchange. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the hypokalemia.

Which laboratory finding in a client with a possible pituitary disorder will the nurse report to the health care provider immediately? A. Blood glucose 148 mg/dL (7.4 mmol/L) B. Blood urea nitrogen (BUN) 40 mg/dL (14.3 mmol/L) C. Serum sodium 110 mEq/L (110 mmol/L) D. Serum potassium 3.2 mEq/L (3.2 mmol/L)

C. Serum sodium 110 mEq/L (110 mmol/L) Rationale: The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L). A result of 110 mEq/L (110 mmol/L) represents severe hyponatremia, requiring immediate action to prevent increased intracranial pressure, seizures, and death as the intravascular fluid shifts into brain tissue. The most likely cause of the problem is an increased vasopressin level that is increasing water reabsorption and diluting the serum sodium level.

A client with opioid depression has received naloxone. Vitals signs are currently recorded as BP 110/70, P 70, R 16, and T 98.9° F. Which additional treatment does the nurse anticipate will be needed? A. Restraints due to naloxone causing agitation B. Activation of the Rapid Response Team C. Supplemental pain medication D. External pacing to regular heartbeat

C. Supplemental pain medication Rationale: Supplemental pain medication will be anticipated, as reversal of the opioid via naloxone reduces the analgesic effect also.

Which action will the nurse recommend to a client with type 1 diabetes on insulin therapy who has been having a morning fasting blood glucose (FBG) level of 160 mg/dL (8.9 mmol/L) and is diagnosed with "dawn phenomenon" to achieve better control? A. Eat a bedtime snack containing equal amounts of protein and carbohydrates." B. Avoid eating any carbohydrate with your evening meal." C. Take your evening insulin dose right before going to bed instead of at supper time." D. Inject the insulin into your arm rather than into the abdomen around the navel."

C. Take your evening insulin dose right before going to bed instead of at supper time." Rationale: A client with "dawn phenomenon," diagnosed by checking blood glucose levels during the night, has morning hyperglycemia that results from a nighttime release of adrenal hormones causing blood glucose elevations at about 5 to 6 a.m. It is managed by providing more insulin for the overnight period (e.g., giving the evening dose of intermediate-acting insulin at 10 p.m. instead of with the evening meal).

An older client's adult child tells the nurse that the client does not want life support. What does the nurse do first? A. Call the legal department to draft the paperwork. B. Thank the adult child for sharing the parent's desires. C. Talk to the client to be sure of their wishes. D. Document the conversation in the electronic health record.

C. Talk to the client to be sure of their wishes. Rationale: The nurse would first talk to the client in order to determine the client's wishes and state of mind. As long as the client is lucid, he or she can articulate his or her own wishes regarding life support or the absence of such.Once the nurse has assessed that the client has certain end-of-life wishes, the nurse can confirm that the client wants these officially documented. If the client agrees, then the legal department can be contacted. Finally, the nurse can thank the adult child for sharing that the client has thoughts about life support, as this was the catalyst that allowed the nurse to further assess the client's wishes. The nurse could not act on the adult child's indications alone.

Which statement regarding trophic (tropic) hormones is true? A. All are categorized as catecholamines. B. Responses are independent of target tissue receptors. C. Their target tissues are always another endocrine gland. D. They represent the final hormone secreted in a complex negative feedback pathway.

C. Their target tissues are always another endocrine gland. Rationale: Trophic (tropic) hormones stimulate the secretion of other hormones from another endocrine gland. Just like any other hormone, a receptor is required for action (receptor can be on the receptor or somewhere else inside the responsive target tissue. Only epinephrine, norepinephrine, and dopamine are catecholamines. None of them are trophic hormones. Trophic hormones represent the initiating hormone or an intermediate hormone in a more complex negative feedback pathway, not the final hormone.

Which urine characteristics indicate to the nurse that the client being managed for diabetes insipidus is responding appropriately to interventions? A. Urine output volume increased; urine specific gravity increased B. Urine output volume increased; urine specific gravity decreased C. Urine output volume decreased; urine specific gravity increased D. Urine output volume decreased; urine specific gravity decreased

C. Urine output volume decreased; urine specific gravity increased Rationale: Diabetes insipidus (DI) occurs with reduced or absent secretion of vasopressin (ADH). As a result, water is excessively excreted, causing a decrease in blood volume and an increase in urine volume. Blood is concentration indicating dehydration and urine is very dilute, as measured by specific gravity, is very low. When interventions to counter act DI are effective, the adult increases water reabsorption so that urine output volume decreases at the same time that urine concentration increases, seen as an increased urine specific gravity.

A nurse caring for a client with Cushing's syndrome who must remain on continued corticosteroid therapy for another health problem will use which of the following actions to prevent harm? A. Urging the client to salt his or her food. B. Testing voided urine for the present of glucose. C. Using non-adhesive methods to secure an IV access. D. Ensuring that the prescribed corticosteroid drug is given on an empty stomach.

C. Using non-adhesive methods to secure an IV access. Rationale: The skin of a client on chronic corticosteroid therapy is thin, very fragile, and easily injured. The client also is a increased risk for infection and an open skin site increases that risk. Using nonadhesive methods to secure an IV access protects the skin from injury. Usually the client on a corticosteroid has problems with sodium retention and is on a salt-restricted diet. Urine testing for glucose not accurate and is no longer performed. Corticosteroids irritate the stomach lining and can cause GI bleeding for many reasons. They are recommended to be taken with food to prevent GI irritation.

Which question asked by a 48-year-old client with sleep apnea whose blood glucose level is elevated suggests to the nurse the possibility of a growth hormone excess? A. "Do you think if I lost weight my sleep apnea would improve?" B. "Why do I feel thirsty all the time?" C. "How can I make my skin less itchy?" D. "Does everyone's feet get bigger during menopause?"

D. "Does everyone's feet get bigger during menopause?" Rationale: Growth hormone is secreted and is needed throughout the life span. When it is secreted in excess in adults, organs can enlarge and bones containing desmoid bone type increase in size, including the facial bones, hands, and feet.The other client questions are reasonable for a client with sleep apnea, hyperglycemia, and menopause to ask.

The nurse is teaching the patient how to administer insulin. What information is essential to include in the plan? A. "Inject the insulin at a 30-degree angle between the fat and muscle." B. "Do not mix any insulins in the same syringe." C. "Avoid administering the insulin into your arm." D. "For the most consistent absorption, inject the insulin into the abdomen."

D. "For the most consistent absorption, inject the insulin into the abdomen." Rationale: The abdomen has the most consistent absorption because the blood flow to the subcutaneous tissue typically is not as affected by muscular movements as it could be in the arm or thigh. Insulin can be administered in the arm. The patient should be instructed to inject insulin at a 45- to 90-degree angle, not a 30-degree angle. Most insulins can be mixed.

Which question is most relevant to ask a male client suspected to have a gonadotropin deficiency? A. "Are you experiencing any pain during sexual intercourse?" B. Do you work with or have hobbies that involve exposure to chemicals?" C. "Have you gained or lost any weight recently?" D. "How often do you need to shave your face?"

D. "How often do you need to shave your face?" Rationale: A gonadotropin deficiency reduces the expression of secondary sexual characteristics and leads to decreased libido and fertility in both male and female clients. Male clients lose facial fair and need to shave less frequently. This change may be the first problem noticed by the client. A deficiency does not result in painful intercourse for men although it can in women from vaginal dryness.

Which patient statement demonstrates understanding of the nurse's teaching for levothyroxine? A. "I can expect to see relief of my symptoms within 1 week." B. "It is best to take the medication with food to prevent gastrointestinal upset." C. "I will double my dose if I gain more than 1 pound/day." D. "I will take this medication first thing in the morning."

D. "I will take this medication first thing in the morning." Rationale: Levothyroxine increases basal metabolism and thus wakefulness. It should be taken first thing in the morning. The patient should not increase the dose. The medication is absorbed best on an empty stomach. Depending on the symptoms, some symptoms may take weeks to improve.

The nurse is educating a client who is about to undergo cardiac surgery with general anesthesia. Which statement by the client indicates the need for further instruction from the nurse? A. "I will have a bandage on my chest." B. "My family will not be able to see me right away." C. "I will wake up with a tube in my throat." D. "Pain medication will take away all of my pain."

D. "Pain medication will take away all of my pain." Rationale: The client's statement that, "Pain medication will take away all of my pain," indicates the need for further instruction. Pain medication will reduce pain, but will not take it away completely.

A male patient 24 h post-op tells the nursing student that his nurse "gave him an extra shot of insulin and there must be some mistake." The nursing student verifies the patient received a sliding scale dose of insulin. What information should the nursing student provide to the patient? A. "The effects of surgery result in a decrease in your metabolic rate; this increases secretion of glucagon and increases your glucose levels." B. "Surgery often results in infection, and infection raises your glucose levels." C. "You received extra insulin today because you have not been eating." D. "Surgery can produce stress, which can produce stress; an additional small amount of insulin helps provide a constant glucose level."

D. "Surgery can produce stress, which can produce stress; an additional small amount of insulin helps provide a constant glucose level." Rationale: Insulin may be administered in adjusted sliding doses that depend on individual blood glucose test results. When the diabetic patient has extreme variances in insulin requirements—such as with stress from hospitalization, surgery, illness, or infection—adjusted dosing or sliding-scale insulin coverage provides a more constant blood glucose level. Blood glucose testing is performed several times a day at specified intervals, usually before meals. A preset scale usually involves directions for the administration of rapid- or short-acting insulin.

What is the nurse's best response to a client newly diagnosed with diabetes who asks why he is always so thirsty? A. "Without insulin, glucose is excreted rather than used in the cells. The loss of glucose directly triggers thirst, especially for sugared drinks." B. "The extra glucose in the blood increases the blood sodium level, which increases your sense of thirst." C. "Without insulin, glucose combines with blood cholesterol, which damages the kidneys, making you feel thirsty even when no water has been lost." D. "The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level."

D. "The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level." Rationale: The high blood glucose levels that are present, because movement of glucose into cells is impaired, increase the osmolarity of the blood. The increased osmolarity stimulates the osmoreceptors in the hypothalamus, which triggers the thirst reflex. In response, the person drinks more water (not sugary fluids or hyperosmotic fluids), which helps dilute blood glucose levels and reduces blood osmolarity.

A client preparing for surgery to remove a cortisol-secreting tumor from the adrenal gland asks the nurse whether the physical changes from the excessive cortisol will go away as a result of the surgery so she can look like herself again. What is the nurse's best response? A. "The surgery is to remove the tumor, not reconstructive surgery." B. "You will notice a great difference in your appearance starting within a week after surgery." C. "All the changes will resolve but may take a year or longer to completely disappear." D. "The fatty changes and and acne will resolve with time but the stretch marks only fade."

D. "The fatty changes and acne will resolve with time but the stretch marks only fade." Rationale: The good news is that the changes that are not related to tissue structure, such as the moon face, buffalo hump, weight gain, truncal obesity, and acne will resolve and go away but may take a year or longer to do so. Her muscles can become stronger and larger again as well. However, the stretch marks will only fade and become less noticeable. Although she did not ask about bone changes and osteoporosis, this may never completely resolve.

What information will the nurse teach the patient who has been prescribed an alpha glucosidase inhibitor? A. "This medication will increase the sensitivity of insulin receptor sites." B. "This medication cannot be used in combination with other antidiabetic agents." C. "This medication will stimulate pancreatic insulin release." D. "This medication will delay the absorption of carbohydrates from the intestines."

D. "This medication will delay the absorption of carbohydrates from the intestines." Rationale: Alpha glucosidase is an enzyme necessary for the absorption of glucose from the GI tract. Inhibiting this enzyme inhibits glucose absorption, delaying rises in postprandial serum glucose levels.

The nurse has just received report on a group of clients. Which client is the nurse's first priority? A. A 42 year old with diabetes insipidus who has a dose of desmopressin due. B. A 35 year old with hyperaldosteronism who has a serum potassium of 3.0 mEq/L (3.0 mmol/L). C. A 50 year old with pituitary adenoma who is reporting a severe headache. D. A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L).

D. A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L). Rationale: The nurse first attends to the client with adrenal insufficiency who has a blood glucose level of 36 mg/dL (2.0 mmol/L). The client's condition is considered a medical emergency and must be assessed and treated immediately.

Which patient should the nurse expect to be most likely to be treated with somatropin? A. An 8-year-old with Prader-Willi syndrome B. A 17-year-old who is 5 feet tall C. A 10-year-old of short stature who has severe asthma D. A 7-year-old diagnosed with growth hormone deficiency

D. A 7-year-old diagnosed with growth hormone deficiency Rationale: For this medication to be used, the patient has to be diagnosed with a growth hormone deficiency, and the epiphyses must not be fused, so the child needs to be young. Severe respiratory conditions, Prader-Willi syndrome, and age of 17 years are contraindications to this medication.

Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites? A. A 55-year-old client who has hypoglycemic unawareness B. An 80-year-old client with type 2 diabetes mellitus C. A 45-year-old client with type 1 diabetes mellitus D. A 75-year-old client whose blood glucose levels show little variation

D. A 75-year-old client whose blood glucose levels show little variation Rationale: Comparison studies have shown wide variation between fingertip and alternate sites, and variation is most evident during times when blood glucose levels are rapidly changing. Clients are taught that there is a lag time for blood glucose levels between the fingertip and other sites when blood glucose levels are changing rapidly and that the fingertip reading is the only safe choice at those times. Because of this lag time, clients who have hypoglycemic unawareness are warned to not ever use alternate sites for SMBG.

The patient is admitted with an acetaminophen overdose. In addition to monitoring liver function results, the nurse would anticipate administering which of the following? A. Activated charcoal B. An antacid C. Naloxone D. Acetylcysteine

D. Acetylcysteine Rationale: When acetaminophen toxicity occurs, acetylcysteine is the antidote, which reduces liver injury by converting toxic metabolites to a nontoxic form.

A patient is admitted for treatment of opioid addiction. Which priority intervention should the nurse implement? A. Assess blood pressure every 8 hours. B. Monitor temperature hourly. C. Administer naloxone. D. Administer methadone.

D. Administer methadone. Rationale: Methadone is a synthetic opioid analgesic with gentler withdrawal symptoms and is the drug of choice for detoxification treatment. The patient's blood pressure needs to be monitored more frequently than every 8 hours for a patient in withdrawal. The patient's temperature is not a concern. Narcan is not administered to the patient in withdrawal from narcotic addiction.

A patient who has been taking morphine for pain is assessed by the nurse. The patient's respiratory rate is 7 per minute, and pupils are 1 mm and unreactive. What is the nurse's immediate action? A. Call a code. B. Start rescue breathing. C. Call anesthesia. D. Administer naloxone.

D. Administer naloxone. Rationale: Morphine overdose can be indicated by unresponsive, pinpoint pupils and respiratory depression. Rescue breathing, calling anesthesia, or calling a code will not correct the underlying problem.

Which action is most important for the nurse to take first after finding a client who has severe hypothyroidism to be unresponsive to attempts to waken her and have a heart rate of 46 beats/min? A. Increasing the IV infusion rate B. Initiating the Rapid Response Team C. temperature D. Applying oxygen by mask

D. Applying oxygen by mask Rationale: The most common cause of death with severe hypothyroidism is respiratory failure with decreased gas exchange. The nurse would apply oxygen first and then initiate the Rapid Response Team. Although a decreased body temperature would support the findings that a client with severe hypothyroidism is worsening, assessing it would not be helpful in this situation. Increasing the IV flow rate may not even improve cardiac output because the slow heart rate is not related to a volume deficit but to reduced myocardial contractility.

In monitoring a patient for adverse effects related to morphine sulfate, which is a priority assessment? A. Auscultate lung sounds. B. Observe for cough reflex. C. Assess circulation. D. Assess for nausea and vomiting.

D. Assess for nausea and vomiting. Rationale: Morphine sulfate can cause nausea and vomiting by stimulating the vomiting center in the brain.

Which action has the highest priority for the nurse to take when a client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." and has vital signs of: T 98.4° F (36.9° C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air? A. Administering oxygen B. Connecting a cardiac monitor C. Assessing arterial blood gas (ABG) values D. Assessing blood glucose level

D. Assessing blood glucose level Rationale: The nurse would first obtain the client's glucose level. Breathing deeply and stating, "I can't catch my breath" is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis (DKA).

The nurse reviews the vital signs of a client diagnosed with Graves disease and notes that the client's temperature is 99.6° F (37.6° C). After notifying the primary health care provider, what is the nurse's best next action? A. Administering acetaminophen B. Observing for the presence of chills C. Initiating the Rapid Response Team D. Assessing cardiac status

D. Assessing cardiac status Rationale: Graves disease is manifested by symptoms of hyperthyroidism and increased metabolic rate, including fever. The nurse must next assess the client's cardiac status as atrial fibrillation or other dysrhythmias may have developed. If the client has a cardiac monitor, the nurse needs to check for any dysrhythmias

When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety? A. Warm the vial in a bowl of warm water until it reaches normal body temperature. B. Return the vial to the pharmacy and open a fresh vial of NPH insulin. C. Roll the vial between the hands until the insulin is clear. D. Check the expiration date and draw up the insulin dose.

D. Check the expiration date and draw up the insulin dose. Rationale: The character of NPH insulin is uniformly cloudy. If the expiration date has not passed it can be safely used. Insulin should never be warmed by placing the vial in water.

For which assessment finding in a client who had a transsphenoidal hypophysectomy yesterday will the nurse notify the primary health care provider immediately? A. Dry lips and oral mucosa on examination B. Nasal drainage that tests negative for glucose C. Urine specific gravity of 1.016 D. Client report of a headache and stiff neck

D. Client report of a headache and stiff neck Rationale: Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client's care. The finding requires the nurse to immediately notify the primary health care provider.Dry lips and mouth are not unusual after surgery. Nasal drainage that tests negative for glucose is normal, expected, and not significant. A urine specific gravity of 1.016 is within normal limits.

Which factor or condition does the nurse expect to result in an increase in a client's production of thyroid hormones (TH)? A. Getting 8 hours of sleep nightly B. Chronic constipation C. Protein-calorie malnutrition D. Cold environmental temperatures

D. Cold environmental temperatures Rationale: Cold and stress are two factors that cause the hypothalamus to secrete thyrotropin-releasing hormone (TRH), which then stimulates the anterior pituitary to secrete thyroid-stimulating hormone (TSH) to increase production of the two major thyroid hormones.

The nurse is designing a program to make vaccines available to as many people as possible. Into which environment is the vaccine most likely to be introduced first? A. Medical home B. Inpatient care C. Long-term care D. Community Health Center

D. Community Health Center Rationale: Community health care incorporates the model of primary care delivery with a population-based approach. It is within this system of care, at the community health center level, that the most people can be immediately reached in order to receive a new vaccine first. Later, the vaccine may be introduced at specialized points of care such as inpatient care, long-term care, and the medical home.

Which factor is most important for the nurse to assess before providing instruction to a client newly diagnosed with diabetes about the disease and its management? A. Current energy level and rest patterns B. Sexual orientation C. Current lifestyle for diet and exercise D. Education and literacy levels

D. Education and literacy levels Rationale: The most important factor for the nurse to determine before providing instruction to the newly diagnosed client with diabetes is the client's educational level and literacy level. A large amount of information must be synthesized. Written instructions are typically given. The client's ability to learn and read is essential to provide the client with instructions and information about diabetes. Although lifestyle would be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.

Which action is most important for the nurse to perform when caring for an older client decreased antidiuretic hormone (ADH) production? A. Inspecting feet and legs for ulcers B. Planning for weight-bearing activities C. Stressing the important of fiber in the diet D. Encouraging fluids every 2 hours

D. Encouraging fluids every 2 hours Rationale: A decrease in ADH production in the older adult causes urine to be more dilute. In this instance, urine might not concentrate when fluid intake is low, allowing for excess water loss. Encouraging fluid intake every 2 hours, even during the night, is important to prevent dehydration.

For which new-onset symptom or behavior will the nurse teach a client taking thyroid hormone replacement therapy (HRT) to report immediately to the primary health care provider? A. Calf muscle cramping B. Runny nose C. Anorexia D. Hand tremors

D. Hand tremors Rationale: Hand tremors are an indication of HRT toxicity with increased central nervous system stimulation. The dose must be decreased to prevent more serious neurologic and cardiac toxicities. Anorexia, runny nose, and muscle cramping are neither side effects of the drug nor indications of toxicity.

In developing a plan of care for a patient receiving morphine sulfate, which nursing diagnosis is a priority? A. Nausea related to medication profile side effect B. Constipation related to gastrointestinal side effects C. Risk for injury related to central nervous system side effects D. Impaired gas exchange related to respiratory depression

D. Impaired gas exchange related to respiratory depression Rationale: Using Maslow's hierarchy of needs and the ABCs of prioritization, impaired gas exchange is a priority.

Which is the most appropriate action for the nurse who is told that a patient typically takes his glipizide with food? A. Inform the patient that the medication must be taken 15 min after a meal. B. Immediately check the patient's blood glucose level. C. Immediately call the health care provider. D. Inform the patient that it is better to take the medication 30 min before a meal.

D. Inform the patient that it is better to take the medication 30 min before a meal. Rationale: Food inhibits the absorption of glipizide, the only sulfonylurea agent that should be given 30 min before a meal. The blood glucose level does not have to be taken right away. The medication is not to be taken after a meal. The health care provider does not have to be called; the nurse should intervene.

Which primary health care provider order will the nurse perform first for a client with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 105 mEq/L (105 mmol/L)? A. Administering an infusion of 150 mL hypertonic saline over the next 3 hours B. Drawing blood for hemoglobin and hematocrit levels C. Measuring serial weights at the same daily with the client wearing the same amount of clothing D. Inserting an indwelling catheter and monitoring urine output

D. Inserting an indwelling catheter and monitoring urine output Rationale: The first intervention the nurse performs is to administer an infusion of 150 mL hypertonic saline over 3 hours. When the serum sodium level is below 115 mEq/L (115 mmol/L), the client is at increased risk for seizures and coma.

The nurse is caring for a patient who is taking levothyroxine and warfarin. Which intervention is a priority for the nurse? A. Weigh patient daily for excessive weight loss. B. Assess peripheral pulses and Homans sign daily. C. Monitor the patient for cardiac dysrhythmias. D. Monitor the patient for increased risk of bleeding.

D. Monitor the patient for increased risk of bleeding. Rationale: Levothyroxine can compete with protein-binding sites of warfarin (Coumadin), allowing more warfarin to be unbound or free, thus increasing the effects of warfarin and the risk of bleeding. This combination does not place the patient at an increased risk of dysrhythmias, weight loss, or deep vein thrombosis.

Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? A. Administering morphine for pain B. Assessing the wound dressing for bleeding C. Hyperextending the neck D. Monitoring oxygen saturation

D. Monitoring oxygen saturation Rationale: Airway assessment and management is always the first priority with every client, especially for a client who has had surgery that involves potential bleeding and edema near the trachea.

The nurse is providing care for a client who recently had a brain attack. Which member of the interprofessional health care team does the nurse identify that can help the client improve skills to perform ADLs? A. Assistive personnel B. Physical therapist C. Licensed social worker D. Occupational therapist

D. Occupational therapist Rationale: The occupational therapist helps clients develop, recover, improve, and maintain ADLs through therapy.

A client is scheduled to have an ileostomy placed. How does the nurse document this type of surgery? A. Diagnostic B. Cosmetic C. Curative D. Palliative

D. Palliative Rationale: Colostomy surgery is categorized as palliative. Palliative surgery is performed to increase the quality of life (and often to reduce pain) while reducing stressors on the body. It is noncurative in nature.

The nurse is assessing a patient taking morphine sulfate. Which assessment requires immediate action? A. Nausea B. Delayed gastric emptying C. Decreased bowel sounds D. Pinpoint pupils

D. Pinpoint pupils Rationale: Pinpoint pupils might be a sign of morphine overdose or toxicity. The nurse needs to act on this finding immediately. Decreased bowel sounds and constipation are expected. Nausea and delayed gastric emptying are expected side effects of morphine sulfate and do not require immediate action.

The nurse is comparing the clinical judgment measurement model (CJMM) and the nursing process. Which step of the CJMM is specific to analysis? A. Generate solutions B. Take actions C. Recognize cues D. Prioritize hypothesis

D. Prioritize hypothesis Rationale: The step of the CJMM that correlates with analysis in the nursing process is to prioritize hypothesis. Also, within this step is analyzing cues. Recognizing cues is assessment, generating solutions is planning, and taking action is implementation.

Which assessment finding in a client with diabetes mellitus indicates to the nurse that the disease is damaging the kidneys? A. White blood cells (WBCs) in the urine during a random urinalysis B. Ketone bodies in the urine during acidosis C. Glucose in the urine during hyperglycemia D. Protein in the urine during a random urinalysis

D. Protein in the urine during a random urinalysis Rationale: Urine should not contain protein and the presence of proteinuria in a client with marks the beginning of renal problems known as diabetic nephropathy, that progresses eventually to end-stage renal disease. Chronically elevated blood glucose levels cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. The excess leakiness allows larger substances, such as proteins, to be filtered into the urine.

The nurse assesses a client's wound 24 hours postoperatively. Which finding causes the nurse to contact the surgeon? A. Sanguineous drainage at the suture site B. Crusting along the incision line C. Serosanguineous drainage on the dressing D. Redness and swelling around the incision

D. Redness and swelling around the incision Rationale: The nurse's concern is redness and swelling around the incision. This needs to be reported to the surgeon because these signs could indicate an infection.

Which assessment is most important for the nurse to monitor in a patient receiving an opioid analgesic? A. Mental status B. Heart rate C. Blood pressure D. Respiratory rate

D. Respiratory rate Rationale: The most serious side effect of narcotic analgesics is respiratory depression.

Which changing trends in a client's serum laboratory values indicate to the nurse that thyroid hormone replacement therapy for hypothyroidism is effective? A. Declining thyroglobulin (Tg) levels; rising thyrotropin receptor antibody (TRAb) levels B. Declining thyroid hormone (TH) levels; rising thyroid-stimulating hormone (TSH) levels C. Rising thyroglobulin (Tg) levels; declining thyrotropin receptor antibody (TRAb) levels D. Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels

D. Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels Rationale: Drug therapy for hypothyroidism hormone replacement therapy with synthetic thyroid hormones, which would result in rising TH levels. As these levels rise, the negative feedback loop, which tries to stimulate the thyroid gland to produce TH would be suppressed, causes declining TSH levels. Thyroglobulin levels are related to active thyroid tissue. In hypothyroidism, these levels are low and drug therapy does not increase them. TRAbs are not a cause of hypothyroidism and do not develop with drug therapy.

Which client report of changes in appearance indicates to the nurse that a client's adrenal insufficiency is related to direct malfunction of the adrenal glands? A. 5-lb weight loss B. Dry, cracked lips C. Thinning pubic hair D. Skin darkening

D. Skin darkening Rationale: Clients whose adrenal insufficiency is caused by adrenal glands that cannot produce appropriate levels of adrenal hormones have overall skin darkening. When the problem is in the adrenal gland and not either the hypothalamus or pituitary, plasma ACTH and melanocyte-stimulating hormone (MSH) levels are elevated in response to the adrenal-hypothalamic-pituitary feedback system. (Both ACTH and MSH are made from the same prehormone molecule.) Anything that stimulates increased production of ACTH also leads to increased production of MSH. Elevated MSH levels result in areas of increased pigmentation. Skin darkening does not occur when adrenal insufficiency is caused by hypofunction of the hypothalamus or pituitary gland.

What should the nurse include in the plan of care for the patient beginning prednisone therapy? A. Administer the medication early evening to coincide with the natural secretion pattern of the adrenal cortex. B. Take the medication only every other day to decrease the risk of adrenal hyperplasia. C. Plan to keep a strict, unchanging schedule to prevent adverse reactions. D. Take the medication with food to diminish the risk of gastric irritation.

D. Take the medication with food to diminish the risk of gastric irritation. Rationale: Glucocorticoids can cause gastric distress and should be administered with food. The normal circadian secretion of the adrenal cortex is early morning to wake the person up, not early evening. These medications should be tapered off slowly to prevent adrenal crisis. The patient takes the medication daily.

The nurse reviewing the preadmission testing laboratory values for a 62-year-old client scheduled for a total knee replacement finds an A1C value of 6.2%. How will the nurse interpret this finding? A. The client's A1C is completely normal B. The client has type 1 diabetes mellitus C. The client has type 2 diabetes mellitus D. The client has prediabetes mellitus

D. The client has prediabetes mellitus Rationale: The normal range for A1C (glycosylated hemoglobin A1c) is between 4% and 6%, with diabetes defined as a consistent level above 6.5%. However, clients whose AIC range between 5.7% and 6.4% are considered to have prediabetes with a greatly increased risk for development of actual diabetes mellitus within the next 5 years. Thus this value is not completely normal and is of concern. A1C levels do not distinguish between type 1 and type 2 diabetes.

Which nursing action reflects Assessing, per the AAPIE model of Assessing, Analyzing, Planning, Implementing, and Evaluating? (Select all that apply.) A. Administers IV furosemide 40 mg as prescribed. B. Sets a goal for client to resume normal activities within 4 weeks following surgery. C. Compares temperature at 0600 with temperature taken at 1200. D. Contacts health care provider after obtaining blood pressure of 200/100. E. Collects information about how client sustained an injury. F. Notes pressure injury of 2 inches by 1 inch on sacrum.

E. Collects information about how client sustained an injury. F. Notes pressure injury of 2 inches by 1 inch on sacrum. Rationale: Assessment involves observing what the client says subjectively, and what the nurse observes objectively. Collecting information about how a client sustained an injury and noting a pressure injury are examples of assessment.

The patient is receiving corticotropin for ACTH deficiency. Which statement by the patient indicates a need for additional teaching? A. "When my symptoms are resolved, I can discontinue the drug." B. "The drug may suppress symptoms of infection." C. "I need to eat foods high in potassium." D. "I can administer the drug subcutaneously."

A. "When my symptoms are resolved, I can discontinue the drug." Rationale: The patient should not discontinue the drug abruptly; the dose of the drug must be tapered over several days. Hypokalemia is possible, so eating foods high in potassium is correct. The drug can be administered subcutaneously.

How will the nurse reply when a client with type 2 diabetes tells the nurse that he would like to have a 12-ounce glass of beer with supper but believes that is now impossible? A. "You can have a beer with a meal if you test yourself for hypoglycemia an hour later." B. "You can have a beer with a meal if you test yourself for hyperglycemia an hour later." C. "There are nonalcoholic beers available that you can substitute for a regular beer." D. "If you gave up dessert, you can still have one beer."

A. "You can have a beer with a meal if you test yourself for hypoglycemia an hour later." Rationale: Alcohol consumption contributes to hypoglycemia. This risk is reduced if the alcohol is consumed with or shortly after a meal. The client is instructed to check blood glucose levels about an hour after alcohol is consumed to determine if either more food is needed or if insulin dosage needs to be adjusted.

What is the generalist registered nurse's role related to patient care within a system? Select all that apply. A. Caring B. Teaching C. Collaborating D. Advocating E. Researching F. Prescribing

A. Caring B. Teaching C. Collaborating D. Advocating E. Researching Rationale: The generalist nurse's roles include caring, teaching, collaborating, advocating, and researching. Prescribing is a role of health care providers such as physicians, physician assistants, and advance practice registered nurses (APRNs).

What should the nurse teach the patient who is prescribed a fentanyl transdermal delivery system? A. Change the patch every 72 hours. B. Change the patch every 24 hours. C. Change the patch when pain recurs. D. Change the patch once a week.

A. Change the patch every 72 hours. Rationale: The fentanyl transdermal delivery system is designed to slowly release analgesic over a 72-hour period. It should not be changed every time that pain recurs, every 24 hours, or once a week.

After the nurse manager at the endocrine clinic has completed the orientation of a new RN, which action by the new RN who is caring for a patient with a goiter and possible hyperthyroidism indicates the charge nurse needs to do more teaching? a. The RN palpates the neck to check thyroid size. b. The RN checks the blood pressure on both arms. c. The RN orders nonmedicated eye drops to lubricate the patients eyes. d. The RN lowers the thermostat to decrease the temperature in the room.

a. The RN palpates the neck to check thyroid size.