MCA1
he nurse is caring for a 50-year-old unconscious female patient who has just been admitted to the PACU after abdominal hysterectomy. How should the nurse position the patient?
Left lateral position
A mask is only required in the restricted area of the surgery dept
True
Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs? a. Choose flat-soled leather shoes. b. Set heating pads on a low temperature. c. Use callus remover for corns or calluses. d. Soak feet in warm water for an hour each day.
a. Choose flat-soled leather shoes.
An older adult patient who is having an annual check-up tells the nurse, "I feel fine, and I don't want to pay for all these unnecessary cancer screening tests!" Which information should the nurse plan to teach this patient? a. Consequences of aging on cell-mediated immunity b. Decrease in antibody production associated with aging c. Impact of poor nutrition on immune function in older people d. Incidence of cancer-stimulating infections in older individuals
a. Consequences of aging on cell-mediated immunity
Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) who are working in the diabetic clinic? a. Measure the ankle-brachial index. b. Check for changes in skin pigmentation. c. Assess for unilateral or bilateral foot drop. d. Ask the patient about symptoms of depression.
a. Measure the ankle-brachial index.
A 34-year-old has a new diagnosis of type 2 diabetes. The nurse will discuss the need to schedule a dilated eye exam a. every 2 years. b. as soon as possible. c. when the patient is 39 years old. d. within the first year after diagnosis.
b. as soon as possible.
The nurse admits a patient to the hospital and develops a plan of care. What components should the nurse include in the nursing diagnosis statement? a. The problem and the suggested patient goals or outcomes b. The problem with possible causes and the planned interventions c. The problem, its cause, and objective data that support the problem d. The problem with an etiology and the signs and symptoms of the problem
d. The problem with an etiology and the signs and symptoms of the problem
A patient who is receiving immunotherapy has just received an allergen injection. Which assessment finding is most important to communicate to the health care provider? a. The patient's IgG level is increased. b. The injection site is red and swollen. c. The patient's allergy symptoms have not improved. d. There is a 2-cm wheal at the site of the allergen injection.
d. There is a 2-cm wheal at the site of the allergen injection.
Which patient with type 1 diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness? A 58-year-old patient with diabetic retinopathy A 73-year-old patient who takes propranolol (Inderal) A 19-year-old patient who is on the school track team Incorrect A 24-year-old patient with a hemoglobin A1C of 8.9%
A 73-year-old patient who takes propranolol (Inderal)
A patient who is receiving an IV antibiotic develops wheezes and dyspnea. In which order should the nurse implement these prescribed actions? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Discontinue the antibiotic infusion. b. Give diphenhydramine (Benadryl) IV. c. Inject epinephrine (Adrenalin) IM or IV. d. Prepare an infusion of dopamine (Intropin). e. Start 100% oxygen using a nonrebreather mask.
A-Discontinue the antibiotic infusion. E-Start 100% oxygen using a nonrebreather mask., C_Inject epinephrine (Adrenalin) IM or IV. B-Give diphenhydramine (Benadryl) IV. D-Prepare an infusion of dopamine (Intropin).
A 65-year-old patient with type 2 diabetes has a urinary tract infection (UTI). The unlicensed assistive personnel (UAP) reported to the nurse that the patient's blood glucose is 642 mg/dL and the patient is hard to arouse. When the nurse assesses the urine, there are no ketones present. What collaborative care should the nurse expect for this patient? Routine insulin therapy and exercise Administer a different antibiotic for the UTI. Cardiac monitoring to detect potassium changes Administer IV fluids rapidly to correct dehydration.
Cardiac monitoring to detect potassium changes
A college student is newly diagnosed with type 1 diabetes. She now has a headache, changes in her vision, and is anxious, but does not have her portable blood glucose monitor with her. Which action should the campus nurse advise her to take? Eat a piece of pizza. Drink some diet pop. Eat 15 g of simple carbohydrates. Take an extra dose of rapid-acting insulin.
Eat 15 g of simple carbohydrates.
A 70 kg post operative patient has an average urine output of 25 mL an hour during the first eight hours. What is the priority nursing interventions?
Evaluate the patient's fluid volume status since surgery and obtain a bladder scan
The nurse is evaluating a 45-year-old patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient is considered one of the classic clinical manifestations of diabetes? Excessive thirst Correct Gradual weight gain Overwhelming fatigue Incorrect Recurrent blurred vision
Excessive thirst
A pt who normally takes 40 units of glargine insulin at bedtime asks the RN what to do about her dose the night before surgery. The best response would be to have her
Get instructions from the surgeons or PCP on any insulin adjustments.
Which physiologic change is associated with fever during inflammatory conditions? Increased blood flow rate Decreased neutrophil action Increased proliferation of T cells Suppressed activity of interferon
Increased proliferation of T cells
Laboratory results have been obtained for a 50-year-old patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? Increased triglyceride levels Increased high-density lipoproteins (HDL) Incorrect Decreased low-density lipoproteins (LDL) Decreased very-low-density lipoproteins (VLDL
Increased triglyceride levels
A client who returns to the nursing unit from post anesthesia care in the pacu is breathing at 6 breaths per minute. The report shows that the client received dialudid pain medication in PACU. What medication should the nurse give to reverse the effects of the dilaudid.
Naloxone
A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? Avoid sick people and wash hands. Obtain comprehensive dental care. Maintain hemoglobin A1c below 7%. Coughing and deep breathing with splinting
Obtain comprehensive dental care.
A patient who has never had any prior surgeries tells the nurse doing the pre-operative assessment about an allergy to bananas and avocados. Which action is most important for the nurse to take?
Possible latex allergy
A patient with pneumonia has a fever of over 103° F. What nursing action is a priority to manage the patient's fever? Administer aspirin on a scheduled basis around the clock. Provide acetaminophen every four hours to maintain consistent blood levels. Administer acetaminophen when the patient's oral temperature exceeds 103.5° F. Provide drug interventions if complementary and alternative therapies have failed.
Provide acetaminophen every four hours to maintain consistent blood levels.
A nurse receives an order for azithromycin ivpb, the nurse questions the order since the laboratory testing reveals no obvious source of infection. What is the best action for the nurse to take:
Question the physicians order
A patient is admitted with diabetes mellitus, malnutrition, and cellulitis. The patient's potassium level is 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result (select all that apply)? The level may be increased as a result of dehydration that accompanies hyperglycemia. The patient may be excreting extra sodium and retaining potassium because of malnutrition. Incorrect The level is consistent with renal insufficiency that can develop with renal nephropathy. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. This level demonstrates adequate treatment of the cellulitis and effective serum glucose control.
The level may be increased as a result of dehydration that accompanies hyperglycemia. The level is consistent with renal insufficiency that can develop with renal nephropathy. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia.
The nurse teaches a patient about drug therapy after a kidney transplant. Which statement by the patient would indicate a need for further instructions? a. "After a couple of years, it is likely that I will be able to stop taking the cyclosporine." b. "If I develop an acute rejection episode, I will need to have other types of drugs given IV." c. "I need to be monitored closely because I have a greater chance of developing malignant tumors." d. "The drugs are given in combination because they inhibit different ways the kidney can be rejected."
a. "After a couple of years, it is likely that I will be able to stop taking the cyclosporine."
Which question during the assessment of a diabetic patient will help the nurse identify autonomic neuropathy? a. "Do you feel bloated after eating?" b. "Have you seen any skin changes?" c. "Do you need to increase your insulin dosage when you are stressed?" d. "Have you noticed any painful new ulcerations or sores on your feet?"
a. "Do you feel bloated after eating?"
Which statement by the patient indicates a need for additional instruction in administering insulin? a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I can buy the 0.5 mL syringes because the line markings will be easier to see." c. "I should draw up the regular insulin first after injecting air into the NPH bottle." d. "I do not need to aspirate the plunger to check for blood before injecting insulin."
a. "I need to rotate injection sites among my arms, legs, and abdomen each day."
A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 10:00 AM b. 12:00 AM c. 2:00 PM d. 4:00 PM
a. 10:00 AM
A patient who has received allergen testing using the cutaneous scratch method has developed itching and swelling at the skin site. Which action should the nurse take first? a. Administer epinephrine. b. Apply topical hydrocortisone. c. Monitor the patient for lower extremity edema. d. Ask the patient about exposure to any new lotions or soaps.
a. Administer epinephrine.
A patient is admitted to the hospital with acute rejection of a kidney transplant. Which intervention will the nurse prepare for this patient? a. Administration of immunosuppressant medications b. Insertion of an arteriovenous graft for hemodialysis c. Placement of the patient on the transplant waiting list d. A blood draw for human leukocyte antigen (HLA) matching
a. Administration of immunosuppressant medications
In order to assist an older diabetic patient to engage in moderate daily exercise, which action is most important for the nurse to take? a. Determine what type of activities the patient enjoys. b. Remind the patient that exercise will improve self-esteem. c. Teach the patient about the effects of exercise on glucose level. d. Give the patient a list of activities that are moderate in intensity.
a. Determine what type of activities the patient enjoys.
A patient arrives in the emergency department with a swollen ankle after an injury incurred while playing soccer. Which action by the nurse is most appropriate? a. Elevate the ankle above heart level. b. Apply a warm moist pack to the ankle. c. Assess the ankle's range of motion (ROM). d. Assess whether the patient can bear weight on the affected ankle.
a. Elevate the ankle above heart level.
The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? a. Give the patient 4 to 6 oz more orange juice. b. Administer the PRN glucagon (Glucagon) 1 mg IM. c. Have the patient eat some peanut butter with crackers. d. Notify the health care provider about the hypoglycemia.
a. Give the patient 4 to 6 oz more orange juice.
A patient is being evaluated for possible atopic dermatitis. The nurse expects elevation of which laboratory value? a. IgE b. IgA c. Basophils d. Neutrophils
a. IgE
A 54-year-old patient is admitted with diabetic ketoacidosis. Which admission order should the nurse implement first? a. Infuse 1 liter of normal saline per hour. b. Give sodium bicarbonate 50 mEq IV push. c. Administer regular insulin 10 U by IV push. d. Start a regular insulin infusion at 0.1 units/kg/hr.
a. Infuse 1 liter of normal saline per hour.
Which information will the nurse consider when deciding what nursing actions to delegate to a licensed practical/vocational nurse (LPN/LVN) who is working on a medical-surgical unit (select all that apply)? a. Institutional policies b. Stability of the patient c. State nurse practice act d. LPN/LVN teaching abilities e. Experience of the LPN/LVN
a. Institutional policies b. Stability of the patient c. State nurse practice act, e. Experience of the LPN/LVN
A 32-year-old patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage? a. Lispro (Humalog) b. Glargine (Lantus) c. Detemir (Levemir) d. NPH (Humulin N)
a. Lispro (Humalog)
Which finding is most important for the nurse to communicate to the health care provider when caring for a patient who is receiving negative pressure wound therapy? a. Low serum albumin level b. Serosanguineous drainage c. Deep red and moist wound bed d. Cobblestone appearance of wound
a. Low serum albumin level
A patient who has diabetes is admitted for an exploratory laparotomy for abdominal pain. When planning interventions to promote wound healing, what is the nurse's highest priority? a. Maintaining the patient's blood glucose within a normal range b. Ensuring that the patient has an adequate dietary protein intake c. Giving antipyretics to keep the temperature less than 102° F (38.9° C) d. Redressing the surgical incision with a dry, sterile dressing twice daily
a. Maintaining the patient's blood glucose within a normal range
A patient with an open leg wound has a white blood cell (WBC) count of 13, 500/µL and a band count of 11%. What action should the nurse take first? a. Obtain wound cultures. b. Start antibiotic therapy. c. Redress the wound with wet-to-dry dressings. d. Continue to monitor the wound for purulent drainage.
a. Obtain wound cultures.
A patient with a bacterial infection has a nursing diagnosis of deficient fluid volume related to excessive diaphoresis. Which outcome would the nurse recognize as most appropriate for this patient? a. Patient has a balanced intake and output. b. Patient's bedding is changed when it becomes damp. c. Patient understands the need for increased fluid intake. d. Patient's skin remains cool and dry throughout hospitalization.
a. Patient has a balanced intake and output.
A 27-year-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? a. Place the patient on a cardiac monitor. b. Administer IV potassium supplements. c. Obtain urine glucose and ketone levels. d. Start an insulin infusion at 0.1 units/kg/hr.
a. Place the patient on a cardiac monitor.
A patient has an open surgical wound on the abdomen that contains deep pink granulation tissue. How would the nurse document this wound? a. Red wound b. Yellow wound c. Full-thickness wound d. Stage III pressure ulcer
a. Red wound
Ten days after receiving a bone marrow transplant, a patient develops a skin rash. What would the nurse suspect is the cause of this patient's skin rash? a. The donor T cells are attacking the patient's skin cells. b. The patient's antibodies are rejecting the donor bone marrow. c. The patient is experiencing a delayed hypersensitivity reaction. d. The patient will need treatment to prevent hyperacute rejection.
a. The donor T cells are attacking the patient's skin cells.
Which patient action indicates a good understanding of the nurse's teaching about the use of an insulin pump? a. The patient programs the pump for an insulin bolus after eating. b. The patient changes the location of the insertion site every week. c. The patient takes the pump off at bedtime and starts it again each morning. d. The patient plans for a diet that is less flexible when using the insulin pump.
a. The patient programs the pump for an insulin bolus after eating.
When admitting a patient with stage III pressure ulcers on both heels, which information obtained by the nurse will have the most impact on wound healing? a. The patient takes insulin daily. b. The patient states that the ulcers are very painful. c. The patient has had the heel ulcers for the last 6 months. d. The patient has several old incisions that have formed keloids.
a. The patient takes insulin daily.
A female patient is scheduled for an oral glucose tolerance test. Which information from the patient's health history is most important for the nurse to communicate to the health care provider? a. The patient uses oral contraceptives. b. The patient runs several days a week. c. The patient has been pregnant three times. d. The patient has a family history of diabetes.
a. The patient uses oral contraceptives.
6. A 55-year-old female patient with type 2 diabetes has a nursing diagnosis of imbalanced nutrition: more than body requirements. Which goal is most important for this patient? a. The patient will reach a glycosylated hemoglobin level of less than 7%. b. The patient will follow a diet and exercise plan that results in weight loss. c. The patient will choose a diet that distributes calories throughout the day. d. The patient will state the reasons for eliminating simple sugars in the diet.
a. The patient will reach a glycosylated hemoglobin level of less than 7%.
The nurse is administering medications to a patient. Which actions by the nurse during this process are consistent with promoting safe delivery of care (select all that apply)? a. Throws away a medication that is not labeled b. Uses a hand sanitizer before preparing a medication c. Identifies the patient by the room number on the door d. Checks lab test results before administering a diuretic e. Gives the patient a list of current medications upon discharge
a. Throws away a medication that is not labeled b. Uses a hand sanitizer before preparing a medication d. Checks lab test results before administering a diuretic e. Gives the patient a list of current medications upon discharge
A nurse asks the patient if pain was relieved after receiving medication. What is the purpose of the evaluation phase of the nursing process? a. To determine if interventions have been effective in meeting patient outcomes b. To document the nursing care plan in the progress notes of the medical record c. To decide whether the patient's health problems have been completely resolved d. To establish if the patient agrees that the nursing care provided was satisfactory
a. To determine if interventions have been effective in meeting patient outcomes
A 38-year-old patient who has type 1 diabetes plans to swim laps daily at 1:00 PM. The clinic nurse will plan to teach the patient to a. check glucose level before, during, and after swimming. b. delay eating the noon meal until after the swimming class. c. increase the morning dose of neutral protamine Hagedorn (NPH) insulin. d. time the morning insulin injection so that the peak occurs while swimming.
a. check glucose level before, during, and after swimming.
A patient who has an infected abdominal wound develops a temperature of 104° F (40° C). All the following interventions are included in the patient's plan of care. In which order should the nurse perform the following actions? a. Administer IV antibiotics. b. Sponge patient with cool water. c. Perform wet-to-dry dressing change. d. Administer acetaminophen (Tylenol).
a. Administer IV antibiotics. d. Administer acetaminophen (Tylenol). b. Sponge patient with cool water. c. Perform wet-to-dry dressing change.
In which order will the nurse take these steps to prepare NPH 20 units and regular insulin 2 units using the same syringe? (Put a comma and a space between each answer choice [A, B, C, D, E]). a. Rotate NPH vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial.
a. Rotate NPH vial. d. Inject 20 units of air into NPH vial. e. Inject 2 units of air into regular insulin vial. b. Withdraw regular insulin. c. Withdraw 20 units of NPH.
The nurse is providing education to nursing staff on quality care initiatives. Which statement would be the most accurate description of the impact of health care financing on quality care? a. "Hospitals are reimbursed for all costs incurred if care is documented electronically." b. "Payment for patient care is primarily based on clinical outcomes and patient satisfaction." c. "If a patient develops a catheter-related infection, the hospital receives additional funding." d. "Because hospitals are accountable for overall care, it is not nursing's responsibility to monitor care delivered by others."
b. "Payment for patient care is primarily based on clinical outcomes and patient satisfaction."
The nurse teaches a student nurse about how to apply the nursing process when providing patient care. Which statement, if made by the student nurse, indicates that teaching was successful? a. "The nursing process is a scientific-based method of diagnosing the patient's health care problems." b. "The nursing process is a problem-solving tool used to identify and treat patients' health care needs." c. "The nursing process is based on nursing theory that incorporates the biopsychosocial nature of humans." d. "The nursing process is used primarily to explain nursing interventions to other health care professionals."
b. "The nursing process is a problem-solving tool used to identify and treat patients' health care needs."
After change-of-shift report, which patient should the nurse assess first? a. 19-year-old with type 1 diabetes who has a hemoglobin A1C of 12% b. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL c. 40-year-old who is pregnant and whose oral glucose tolerance test is 202 mg/dL d. 50-year-old who uses exenatide (Byetta) and is complaining of acute abdominal pain
b. 23-year-old with type 1 diabetes who has a blood glucose of 40 mg/dL
A diabetic patient who has reported burning foot pain at night receives a new prescription. Which information should the nurse teach the patient about amitriptyline (Elavil)? a. Amitriptyline decreases the depression caused by your foot pain. b. Amitriptyline helps prevent transmission of pain impulses to the brain. c. Amitriptyline corrects some of the blood vessel changes that cause pain. d. Amitriptyline improves sleep and makes you less aware of nighttime pain.
b. Amitriptyline helps prevent transmission of pain impulses to the brain.
A patient who is anxious and has difficulty breathing seeks treatment after being stung by a wasp. What is the nurse's priority action? a. Have the patient lie down. b. Assess the patient's airway. c. Administer high-flow oxygen. d. Remove the stinger from the site.
b. Assess the patient's airway.
The nurse is preparing to teach a 43-year-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first? a. Ask the patient's family to participate in the diabetes education program. b. Assess the patient's perception of what it means to have diabetes mellitus. c. Demonstrate how to check glucose using capillary blood glucose monitoring. d. Discuss the need for the patient to actively participate in diabetes management.
b. Assess the patient's perception of what it means to have diabetes mellitus.
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select all that apply)? a. Chest x-ray b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria e. Complete blood count (CBC) f. Monofilament testing of the foot
b. Blood pressure c. Serum creatinine d. Urine for microalbuminuria f. Monofilament testing of the foot
An active 28-year-old male with type 1 diabetes is being seen in the endocrine clinic. Which finding may indicate the need for a change in therapy? a. Hemoglobin A1C level 6.2% b. Blood pressure 146/88 mmHg c. Heart rate at rest 58 beats/minute d. High density lipoprotein (HDL) level 65 mg/dL
b. Blood pressure 146/88 mmHg
The nurse assesses a patient's surgical wound on the first postoperative day and notes redness and warmth around the incision. Which action by the nurse is most appropriate? a. Obtain wound cultures. b. Document the assessment. c. Notify the health care provider. d. Assess the wound every 2 hours.
b. Document the assessment.
An adolescent patient seeks care in the emergency department after sharing needles for heroin injection with a friend who has hepatitis B. To provide immediate protection from infection, what medication will the nurse administer? a. Corticosteroids b. Gamma globulin c. Hepatitis B vaccine d. Fresh frozen plasma
b. Gamma globulin
Which action should the nurse take after a 36-year-old patient treated with intramuscular glucagon for hypoglycemia regains consciousness? a. Assess the patient for symptoms of hyperglycemia. b. Give the patient a snack of peanut butter and crackers. c. Have the patient drink a glass of orange juice or nonfat milk. d. Administer a continuous infusion of 5% dextrose for 24 hours.
b. Give the patient a snack of peanut butter and crackers.
Which information will the nurse include when teaching a 50-year-old patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)? a. Glyburide decreases glucagon secretion from the pancreas. b. Glyburide stimulates insulin production and release from the pancreas. c. Glyburide should be taken even if the morning blood glucose level is low. d. Glyburide should not be used for 48 hours after receiving IV contrast media.
b. Glyburide stimulates insulin production and release from the pancreas.
A home care nurse is planning care for a patient who has just been diagnosed with type 2 diabetes mellitus. Which task is appropriate for the nurse to delegate to the home health aide? a. Assist the patient to choose appropriate foods. b. Help the patient with a daily bath and oral care. c. Check the patient's feet for signs of breakdown. d. Teach the patient how to monitor blood glucose.
b. Help the patient with a daily bath and oral care.
Which laboratory value reported to the nurse by the unlicensed assistive personnel (UAP) indicates the most urgent need for the nurse's assessment of the patient? a. Bedtime glucose of 140 mg/dL b. Noon blood glucose of 52 mg/dL c. Fasting blood glucose of 130 mg/dL d. 2-hr postprandial glucose of 220 mg/dL
b. Noon blood glucose of 52 mg/dL
The nurse teaches a patient diagnosed with systemic lupus erythematosus (SLE) about plasmapheresis. What instructions about plasmapheresis should the nurse include in the teaching plan? a. Plasmapheresis will eliminate eosinophils and basophils from blood. b. Plasmapheresis will remove antibody-antigen complexes from circulation. c. Plasmapheresis will prevent foreign antibodies from damaging various body tissues. d. Plasmapheresis will decrease the damage to organs caused by attacking T lymphocytes.
b. Plasmapheresis will remove antibody-antigen complexes from circulation.
The nurse is taking a health history from a 29-year-old pregnant patient at the first prenatal visit. The patient reports no personal history of diabetes but has a parent who is diabetic. Which action will the nurse plan to take first? a. Teach the patient about administering regular insulin. b. Schedule the patient for a fasting blood glucose level. c. Discuss an oral glucose tolerance test for the twenty-fourth week of pregnancy. d. Provide teaching about an increased risk for fetal problems with gestational diabetes.
b. Schedule the patient for a fasting blood glucose level.
The nurse provides discharge instructions to a patient who has an immune deficiency involving the T lymphocytes. Which screening should the nurse include in the teaching plan for this patient? a. Screening for allergies b. Screening for malignancy c. Antibody deficiency screening d. Screening for autoimmune disorders
b. Screening for malignancy
Which patient action indicates good understanding of the nurse's teaching about administration of aspart (NovoLog) insulin? a. The patient avoids injecting the insulin into the upper abdominal area. b. The patient cleans the skin with soap and water before insulin administration. c. The patient stores the insulin in the freezer after administering the prescribed dose. d. The patient pushes the plunger down while removing the syringe from the injection site.
b. The patient cleans the skin with soap and water before insulin administration.
The nurse identifies a need for additional teaching when the patient who is self-monitoring blood glucose a. washes the puncture site using warm water and soap. b. chooses a puncture site in the center of the finger pad. c. hangs the arm down for a minute before puncturing the site. d. says the result of 120 mg indicates good blood sugar control.
b. chooses a puncture site in the center of the finger pad.
An unresponsive patient with type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemic syndrome (HHS). The nurse will anticipate the need to a. give a bolus of 50% dextrose. b. insert a large-bore IV catheter. c. initiate oxygen by nasal cannula. d. administer glargine (Lantus) insulin.
b. insert a large-bore IV catheter.
Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? a. Insulin is not used to control blood glucose in patients with type 2 diabetes. b. Complications of type 2 diabetes are less serious than those of type 1 diabetes. c. Changes in diet and exercise may control blood glucose levels in type 2 diabetes. d. Type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma.
b. Changes in diet and exercise may control blood glucose levels in type 2 diabetes.
The nurse is assessing a 22-year-old patient experiencing the onset of symptoms of type 1 diabetes. Which question is most appropriate for the nurse to ask? a. "Are you anorexic?" b. "Is your urine dark colored?" c. "Have you lost weight lately?" d. "Do you crave sugary drinks?"
c. "Have you lost weight lately?"
The nurse determines a need for additional instruction when the patient with newly diagnosed type 1 diabetes says which of the following? a. "I can have an occasional alcoholic drink if I include it in my meal plan." b. "I will need a bedtime snack because I take an evening dose of NPH insulin." c. "I can choose any foods, as long as I use enough insulin to cover the calories." d. "I will eat something at meal times to prevent hypoglycemia, even if I am not hungry."
c. "I can choose any foods, as long as I use enough insulin to cover the calories."
Which statement by a patient would alert the nurse to a possible immunodeficiency disorder? a. "I take one baby aspirin every day to prevent stroke." b. "I usually eat eggs or meat for at least 2 meals a day." c. "I had my spleen removed many years ago after a car accident." d. "I had a chest x-ray 6 months ago when I had walking pneumonia."
c. "I had my spleen removed many years ago after a car accident."
After the nurse has finished teaching a patient who has a new prescription for exenatide (Byetta), which patient statement indicates that the teaching has been effective? a. "I may feel hungrier than usual when I take this medicine." b. "I will not need to worry about hypoglycemia with the Byetta." c. "I should take my daily aspirin at least an hour before the Byetta." d. "I will take the pill at the same time I eat breakfast in the morning."
c. "I should take my daily aspirin at least an hour before the Byetta."
A patient who collects honey to earn supplemental income has developed a hypersensitivity to bee stings. Which statement, if made by the patient, would indicate a need for additional teaching? a. "I need to find another way to earn extra money." b. "I will get a prescription for epinephrine and learn to self-inject it." c. "I will plan to take oral antihistamines daily before going to work." d. "I should wear a Medic-Alert bracelet indicating my allergy to bee stings."
c. "I will plan to take oral antihistamines daily before going to work."
Which teaching should the nurse provide about intradermal skin testing to a patient with possible allergies? a. "Do not eat anything for about 6 hours before the testing." b. "Take an oral antihistamine about an hour before the testing." c. "Plan to wait in the clinic for 20 to 30 minutes after the testing." d. "Reaction to the testing will take about 48 to 72 hours to occur."
c. "Plan to wait in the clinic for 20 to 30 minutes after the testing."
After change-of-shift report, which patient will the nurse assess first? a. 19-year-old with type 1 diabetes who was admitted with possible dawn phenomenon b. 35-year-old with type 1 diabetes whose most recent blood glucose reading was 230 mg/dL c. 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa d. 68-year-old with type 2 diabetes who has severe peripheral neuropathy and complains of burning foot pain
c. 60-year-old with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa
The charge nurse is assigning rooms for new admissions. Which patient would be the most appropriate roommate for a patient who has acute rejection of an organ transplant? a. A patient who has viral pneumonia b. A patient with second-degree burns c. A patient who is recovering from an anaphylactic reaction to a bee sting d. A patient with graft-versus-host disease after a recent bone marrow transplant
c. A patient who is recovering from an anaphylactic reaction to a bee sting
The nurse is caring for an older adult patient who had surgery to repair a fractured hip. The patient needs continued nursing care and physical therapy to improve mobility before returning home. The nurse will help to arrange for transfer of this patient to which facility? a. A skilled care facility b. A residential care facility c. A transitional care facility d. An intermediate care facility
c. A transitional care facility
When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Communicate the blood glucose level and insulin dose to the circulating nurse in surgery. b. Discuss the reason for the use of insulin therapy during the immediate postoperative period. c. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery. d. Plan strategies to minimize the risk for hypoglycemia or hyperglycemia during the postoperative period.
c. Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
Immediately after the nurse administers an intracutaneous injection of an allergen on the forearm, a patient complains of itching at the site and of weakness and dizziness. What action should the nurse take first? a. Remind the patient to remain calm. b. Administer subcutaneous epinephrine. c. Apply a tourniquet above the injection site. d. Rub a local antiinflammatory cream on the site.
c. Apply a tourniquet above the injection site.
TOP: Nursing Process: Implementation MSC: NCLEX: Health Promotion and Maintenance 2. A new mother expresses concern about her baby developing allergies and asks what the health care provider meant by "passive immunity." Which example should the nurse use to explain this type of immunity? a. Early immunization b. Bone marrow donation c. Breastfeeding her infant d. Exposure to communicable diseases
c. Breastfeeding her infant
The health care provider asks the nurse whether a patient's angioedema has responded to prescribed therapies. Which assessment should the nurse perform? a. Ask the patient about any clear nasal discharge. b. Obtain the patient's blood pressure and heart rate. c. Check for swelling of the patient's lips and tongue. d. Assess the patient's extremities for wheal and flare lesions.
c. Check for swelling of the patient's lips and tongue.
A nurse is caring for a group of patients on the medical-surgical unit with the help of one float registered nurse (RN), one unlicensed assistive personnel (UAP), and one licensed practical/vocational nurse (LPN/LVN). Which assignment, if delegated by the nurse, would be inappropriate? a. Measurement of a patient's urine output by UAP b. Administration of oral medications by LPN/LVN c. Check for the presence of bowel sounds and flatulence by UAP d. Care of a patient with diabetes by RN who usually works on the pediatric unit
c. Check for the presence of bowel sounds and flatulence by UAP
The health care provider suspects the Somogyi effect in a 50-year-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take? a. Avoid snacking at bedtime. b. Increase the rapid-acting insulin dose. c. Check the blood glucose during the night d. Administer a larger dose of long-acting insulin.
c. Check the blood glucose during the night
The nurse, who is reviewing a clinic patient's medical record, notes that the patient missed the previous appointment for weekly immunotherapy. Which action by the nurse is most appropriate? a. Schedule an additional dose that week. b. Administer the usual dosage of the allergen. c. Consult with the health care provider about giving a lower allergen dose. d. Re-evaluate the patient's sensitivity to the allergen with a repeat skin test.
c. Consult with the health care provider about giving a lower allergen dose.
8. While obtaining a health history from a patient, the nurse learns that the patient has a history of allergic rhinitis and multiple food allergies. Which action by the nurse is most appropriate? a. Encourage the patient to carry an epinephrine kit in case a type IV allergic reaction to latex develops. b. Advise the patient to use oil-based hand creams to decrease contact with natural proteins in latex gloves. c. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy. d. Recommend that the patient use vinyl gloves instead of latex gloves in preventing blood-borne pathogen contact.
c. Document the patient's allergy history and be alert for any clinical manifestations of a type I latex allergy.
A patient has been admitted to the hospital for surgery and tells the nurse, "I do not feel comfortable leaving my children with my parents." Which action should the nurse take next? a. Reassure the patient that these feelings are common for parents. b. Have the patient call the children to ensure that they are doing well. c. Gather more data about the patient's feelings about the child-care arrangements. d. Call the patient's parents to determine whether adequate child care is being provided.
c. Gather more data about the patient's feelings about the child-care arrangements.
A few weeks after an 82-year-old with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy and taught about appropriate diet and exercise, the home health nurse makes a visit. Which finding by the nurse is most important to discuss with the health care provider? a. Hemoglobin A1C level is 7.9%. b. Last eye exam was 18 months ago. c. Glomerular filtration rate is decreased. d. Patient has questions about the prescribed diet.
c. Glomerular filtration rate is decreased.
A patient's 4 × 3-cm leg wound has a 0.4 cm black area in the center of the wound surrounded by yellow-green semiliquid material. Which dressing should the nurse apply to the wound? a. Dry gauze dressing (Kerlix) b. Nonadherent dressing (Xeroform) c. Hydrocolloid dressing (DuoDerm) d. Transparent film dressing (Tegaderm)
c. Hydrocolloid dressing (DuoDerm)
A patient who is paralyzed on the left side of the body after a stroke develops a pressure ulcer on the left hip. Which nursing diagnosis is most appropriate? a. Impaired physical mobility related to left-sided paralysis b. Risk for impaired tissue integrity related to left-sided weakness c. Impaired skin integrity related to altered circulation and pressured. d. Ineffective tissue perfusion related to inability to move independently
c. Impaired skin integrity related to altered circulation and pressured.
Which nursing diagnosis statement is written correctly? a. Altered tissue perfusion related to heart failure b. Risk for impaired tissue integrity related to sacral redness c. Ineffective coping related to response to biopsy test results d. Altered urinary elimination related to urinary tract infection
c. Ineffective coping related to response to biopsy test results
A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first? a. Infuse dextrose 50% by slow IV push. b. Administer 1 mg glucagon subcutaneously. c. Obtain a glucose reading using a finger stick. d. Have the patient drink 4 ounces of orange juice.
c. Obtain a glucose reading using a finger stick.
A nurse is caring for a patient with heart failure. Which task is appropriate for the nurse to delegate to experienced unlicensed assistive personnel (UAP)? a. Monitor for shortness of breath or fatigue after ambulation. b. Instruct the patient about the need to alternate activity and rest. c. Obtain the patient's blood pressure and pulse rate after ambulation. d. Determine whether the patient is ready to increase the activity level.
c. Obtain the patient's blood pressure and pulse rate after ambulation.
Which patient should the nurse assess first? a. Patient with urticaria after receiving an IV antibiotic b. Patient who has graft-versus-host disease and severe diarrhea c. Patient who is sneezing after having subcutaneous immunotherapy d. Patient with multiple chemical sensitivities who has muscle stiffness
c. Patient who is sneezing after having subcutaneous immunotherapy
A nurse has obtained donor tissue typing information about a patient who is waiting for a kidney transplant. Which results should be reported to the transplant surgeon? a. Patient is Rh positive and donor is Rh negative b. Six antigen matches are present in HLA typing c. Results of patient-donor cross matching are positive d. Panel of reactive antibodies (PRA) percentage is low
c. Results of patient-donor cross matching are positive
A patient with a systemic bacterial infection feels cold and has a shaking chill. Which assessment finding will the nurse expect next? a. Skin flushing b. Muscle cramps c. Rising body temperature d. Decreasing blood pressure
c. Rising body temperature
A patient from a long-term care facility is admitted to the hospital with a sacral pressure ulcer. The base of the wound is yellow and involves subcutaneous tissue. How should the nurse classify this pressure ulcer? a. Stage I b. Stage II c. Stage III d. Stage IV
c. Stage III
Which information is most important for the nurse to report to the health care provider before a patient with type 2 diabetes is prepared for a coronary angiogram? a. The patient's most recent HbA1C was 6.5%. b. The patient's admission blood glucose is 128 mg/dL. c. The patient took the prescribed metformin (Glucophage) today. d. The patient took the prescribed captopril (Capoten) this morning.
c. The patient took the prescribed metformin (Glucophage) today.
After receiving a change-of-shift report, which patient should the nurse assess first? a. The patient who has multiple black wounds on the feet and ankles b. The newly admitted patient with a stage IV pressure ulcer on the coccyx c. The patient who has been receiving chemotherapy and has a temperature of 102° F d. The patient who needs to be medicated with multiple analgesics before a scheduled dressing change
c. The patient who has been receiving chemotherapy and has a temperature of 102° F
The nurse interviews a patient while completing the health history and physical examination. What is the purpose of the assessment phase of the nursing process? a. To teach interventions that relieve health problems b. To use patient data to evaluate patient care outcomes c. To obtain data with which to diagnose patient problems d. To help the patient identify realistic outcomes for health problems
c. To obtain data with which to diagnose patient problems
A 26-year-old patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to administer the morning insulin? a. thigh. b. buttock. c. abdomen. d. upper arm.
c. abdomen.
A 48-year-old male patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). The nurse will plan to teach the patient about a. self-monitoring of blood glucose. b. using low doses of regular insulin. c. lifestyle changes to lower blood glucose. d. effects of oral hypoglycemic medications.
c. lifestyle changes to lower blood glucose.
A 26-year-old female with type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. The nurse advises the patient to a. use only the lispro insulin until the symptoms are resolved. b. limit intake of calories until the glucose is less than 120 mg/dL. c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. d. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%.
c. monitor blood glucose every 4 hours and notify the clinic if it continues to rise.
When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone (Deltasone). The nurse will anticipate that the patient may a. need a diet higher in calories while receiving prednisone. b. develop acute hypoglycemia while taking the prednisone. c. require administration of insulin while taking prednisone. d. have rashes caused by metformin-prednisone interactions.
c. require administration of insulin while taking prednisone.
The nurse completes an admission database and explains that the plan of care and discharge goals will be developed with the patient's input. The patient states, "How is this different from what the doctor does?" Which response would be most appropriate for the nurse to make? a. "The role of the nurse is to administer medications and other treatments prescribed by your doctor." b. "The nurse's job is to help the doctor by collecting information and communicating any problems that occur." c. "Nurses perform many of the same procedures as the doctor, but nurses are with the patients for a longer time than the doctor." d. "In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health."
d. "In addition to caring for you while you are sick, the nurses will assist you to develop an individualized plan to maintain your health."
The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching? a. "If I overeat at a meal, I will still take the usual dose of medication." b. "Other medications besides the Glucotrol may affect my blood sugar." c. "When I am ill, I may have to take insulin to control my blood sugar." d. "My diabetes won't cause complications because I don't need insulin."
d. "My diabetes won't cause complications because I don't need insulin."
The nurse describes to a student nurse how to use evidence-based practice guidelines when caring for patients. Which statement, if made by the nurse, would be the most accurate? a. "Inferences from clinical research studies are used as a guide." b. "Patient care is based on clinical judgment, experience, and traditions." c. "Data are evaluated to show that the patient outcomes are consistently met." d. "Recommendations are based on research, clinical expertise, and patient preferences."
d. "Recommendations are based on research, clinical expertise, and patient preferences."
The nurse should plan to use a wet-to-dry dressing for which patient? a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas
d. A patient who has a wound with purulent drainage and dry brown areas
A clinic patient is experiencing an allergic reaction to an unknown allergen. Which action is most appropriate for the registered nurse (RN) to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Perform a focused physical assessment. b. Obtain the health history from the patient. c. Teach the patient about the various diagnostic studies. d. Administer skin testing by the cutaneous scratch method.
d. Administer skin testing by the cutaneous scratch method.
The nurse will perform which action when doing a wet-to-dry dressing change on a patient's stage III sacral pressure ulcer? a. Soak the old dressings with sterile saline 30 minutes before removing them. b. Pour sterile saline onto the new dry dressings after the wound has been packed. c. Apply antimicrobial ointment before repacking the wound with moist dressings. d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change.
d. Administer the ordered PRN hydrocodone (Lortab) 30 minutes before the dressing change
A patient with rheumatoid arthritis has been taking corticosteroids for 11 months. Which nursing action is most likely to detect early signs of infection in this patient? a. Monitor white blood cell count. b. Check the skin for areas of redness. c. Check the temperature every 2 hours. d. Ask about fatigue or feelings of malaise.
d. Ask about fatigue or feelings of malaise.
A young male patient who is a paraplegic has a stage II sacral pressure ulcer and is being cared for at home by his mother. To prevent further tissue damage, what instructions are most important for the nurse to teach the mother? a. Change the patient's bedding frequently. b. Use a hydrocolloid dressing over the ulcer. c. Record the size and appearance of the ulcer weekly. d. Change the patient's position at least every 2 hours.
d. Change the patient's position at least every 2 hours.
A young adult patient who is receiving antibiotics for an infected leg wound has a temperature of 101.8° F (38.7° C). Which action by the nurse is most appropriate? a. Apply a cooling blanket. b. Notify the health care provider. c. Give the prescribed PRN aspirin (Ascriptin) 650 mg. d. Check the patient's oral temperature again in 4 hours.
d. Check the patient's oral temperature again in 4 hours.
A nurse is assigned as a case manager for a hospitalized patient with a spinal cord injury. The patient can expect the nurse functioning in this role to perform which activity? a. Care for the patient during hospitalization for the injuries. b. Assist the patient with home care activities during recovery. c. Determine what medical care the patient needs for optimal rehabilitation. d. Coordinate the services that the patient receives in the hospital and at home.
d. Coordinate the services that the patient receives in the hospital and at home.
A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient? a. Urine dipstick for glucose b. Oral glucose tolerance test c. Fasting blood glucose level d. Glycosylated hemoglobin level
d. Glycosylated hemoglobin level
The nurse documenting the patient's progress in the care plan in the electronic health record before an interdisciplinary discharge conference is demonstrating competency in which QSEN category? a. Patient-centered care b. Quality improvement c. Evidence-based practice d. Informatics and technology
d. Informatics and technology
The nurse is caring for a patient undergoing plasmapheresis. The nurse should assess the patient for which clinical manifestation? a. Shortness of breath b. High blood pressure c. Transfusion reaction d. Numbness and tingling
d. Numbness and tingling
Which task is appropriate for the nurse to delegate to a licensed practical/vocational nurse (LPN/LVN)? a. Complete the initial admission assessment and plan of care. b. Document teaching completed before a diagnostic procedure. c. Instruct a patient about low-fat, reduced sodium dietary restrictions. d. Obtain bedside blood glucose on a patient before insulin administration.
d. Obtain bedside blood glucose on a patient before insulin administration.
The nurse is caring for a patient with diabetes who had abdominal surgery 3 days ago. Which finding is most important for the nurse to report to the health care provider? a. Blood glucose 136 mg/dL b. Oral temperature 101° F (38.3° C) c. Patient complaint of increased incisional pain d. Separation of the proximal wound edges by 1 cm
d. Separation of the proximal wound edges by 1 cm
After the home health nurse teaches a patient's family member about how to care for a sacral pressure ulcer, which finding indicates that additional teaching is needed? a. The family member uses a lift sheet to reposition the patient. b. The family member uses clean tap water to clean the wound. c. The family member places contaminated dressings in a plastic grocery bag. d. The family member dries the wound using a hair dryer set on a low setting.
d. The family member dries the wound using a hair dryer set on a low setting.
A new nurse performs a dressing change on a stage II left heel pressure ulcer. Which action by the new nurse indicates a need for further teaching about pressure ulcer care? a. The new nurse uses a hydrocolloid dressing (DuoDerm) to cover the ulcer. b. The new nurse inserts a sterile cotton-tipped applicator into the pressure ulcer. c. The new nurse irrigates the pressure ulcer with sterile saline using a 30-mL syringe. d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.
d. The new nurse cleans the ulcer with a sterile dressing soaked in half-strength peroxide.
Which action by a patient indicates that the home health nurse's teaching about glargine and regular insulin has been successful? a. The patient administers the glargine 30 minutes before each meal. b. The patient's family prefills the syringes with the mix of insulins weekly. c. The patient draws up the regular insulin and then the glargine in the same syringe. d. The patient disposes of the open vials of glargine and regular insulin after 4 weeks.
d. The patient disposes of the open vials of glargine and regular insulin after 4 weeks.
An older adult patient has a prescription for cyclosporine following a kidney transplant. Which information in the patient's health history has the most implications for planning patient teaching about the medication at this time? a. The patient restricts salt to treat prehypertension. b. The patient drinks 3 to 4 quarts of fluids every day. c. The patient has many concerns about the effects of cyclosporine. d. The patient has a glass of grapefruit juice every day for breakfast.
d. The patient has a glass of grapefruit juice every day for breakfast.
The nurse is interviewing a new patient with diabetes who receives rosiglitazone (Avandia) through a restricted access medication program. What is most important for the nurse to report immediately to the health care provider? a. The patient's blood pressure is 154/92. b. The patient has a history of emphysema. c. The patient's blood glucose is 86 mg/dL. d. The patient has chest pressure when walking.
d. The patient has chest pressure when walking.
3. A 28-year-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching? a. The patient always carries hard candies when engaging in exercise. b. The patient goes for a vigorous walk when his glucose is 200 mg/dL. c. The patient has a peanut butter sandwich before going for a bicycle ride. d. The patient increases daily exercise when ketones are present in the urine.
d. The patient increases daily exercise when ketones are present in the urine.
The nurse could delegate care of which patient to a licensed practical/vocational nurse (LPN/LVN)? a. The patient who has increased tenderness and swelling around a leg wound b. The patient who was just admitted after suturing of a full-thickness arm wound c. The patient who needs teaching about home care for a draining abdominal wound d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer
d. The patient who requires a hydrocolloid dressing change for a stage III sacral ulcer
Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)? a. The patient's blood glucose level is 174 mg/dL. b. The patient has gained 2 lb (0.9 kg) since yesterday. c. The patient is scheduled for a chest x-ray in an hour. d. The patient's blood urea nitrogen (BUN) level is 52 mg/dL.
d. The patient's blood urea nitrogen (BUN) level is 52 mg/dL.
A hospitalized diabetic patient received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. To prevent hypoglycemia, the best action by the nurse is to a. save the lunch tray for the patient's later return to the unit. b. ask that diagnostic testing area staff to start a 5% dextrose IV. c. send a glass of milk or orange juice to the patient in the diagnostic testing area. d. request that if testing is further delayed, the patient be returned to the unit to eat.
d. request that if testing is further delayed, the patient be returned to the unit to eat.
The nurse uses the Situation-Background-Assessment-Recommendation (SBAR) format to communicate a change in patient status to a health care provider. In which order should the nurse make the following statements? a. "The patient needs to be evaluated immediately and may need intubation and mechanical ventilation." b. "The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low." c. "The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable." d. "This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour."
d. "This is the nurse on the surgical unit. After assessing the patient, I am very concerned about increased shortness of breath over the past hour." b. "The patient was admitted yesterday with heart failure and has been receiving furosemide (Lasix) for diuresis, but urine output has been low." c. "The patient has crackles audible throughout the posterior chest and the most recent oxygen saturation is 89%. Her condition is very unstable." a. "The patient needs to be evaluated immediately and may need intubation and mechanical ventilation."
