NR 324 Exam 1 review

nurse is preparing to administer lispro insulin to client with type 1 DM. Which of the following actions should the nurse take?

Assess for hypoglycemia 4 hours after insulin injection

a nurse is providing instructions to a client with chronic kidney disease. The nurse should instruct the client to limit which of the following nutrients? (SATA) a. Calcium b. phosphorous c. calories d. protein e. sodium

a. Calcium b. phosphorous d. protein e. sodium

A 42-year-old woman with Meniere's disease is admitted with vertigo, nausea, and vomiting. Which nursing intervention will be included in the care plan? a. Dim the lights in the patients room. b. Encourage increased oral fluid intake. c. Change the patients position every 2 hours. d. Keep the head of the bed elevated 30 degrees

a. Dim the lights in the patients room.

a nurse is providing instruction to a client with a new diagnosis of type 2 diabetes mellitus. the nurse should recongnize that the client understands the information when the client identifies which of the following manifestations? (SATA) a. Tachycardia b. blurred vision c. moist, clammy skin d. polyuria e. polydipsia

a. Tachycardia b. blurred vision c. moist, clammy skin

nurse is reviewing lab test results from the client with prerenal acute kidney injury. (AKI) which of the following electrolyte imbalances should the nurse expect? (SATA) a. hyperkalemia b. hypercalcemia c. hypernatremia d. hypophosphalemia

a. hyperkalemia b. hypercalcemia

a nurse is planning care for a client with a new diagnosis of diabetes insipidus, which of the following interventions should the nurse include in the plan of care? a. measure blood glucose levels every 4 hr b. administer a diuretic c. initiate fluid restrictions d. check urine specific gravity.

d. check urine specific gravity.

a nurse is reviewing the lab results for four clients. the nurse should recognize which of the following clients has a manifestation of hypoparathyroidism? a. client who has a magnesium 1.8 mEq/L b. client who has vitamin D of 25mg/mL c. client who has calcium 9.8 mg/dL d. client who has phosphate of 5.6 mg/dL

d. client who has phosphate of 5.6 mg/dL

a nurse is instructing a client with type 1 diabetes mellitus about avoiding hypoglycemia when exercising. which of the following instructions should the nurse include? a. avoid consuming carbohydrates for at least 1 hour following prolonged exercise. b. avoid exercising if your blood glucose level is greater than 150 mg/dl c. increase your insulin dose before planned exercise d. consume carbohydrates before exercise if your blood glucose level is less than 100mg/dl

d. consume carbohydrates before exercise if your blood glucose level is less than 100mg/dlm

a nurse is reinforcing teaching with a client prescribed levothyroxine to treat hypothyroidism. what information should the nurse include in the instructions? (SATA) a. report increased heart rate b. the medication will be stopped after 14 days c. medication should not be discontinued without consulting the health care provider d. weight gain is expected while taking this medication e. routine monitoring of thyroid levels is necessary.

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nurse is caring for a client who is 1 day postop following a subtotal thyroidectomy, client reports tingling sensations in hands, soles of feet and around lips. which finding should the nurse assess the client for?

Chvostek's sign

nurse is assessing a client who has type 1 DM, finds client laying in bed, sweating and reports feeling anxious. Whihc of the following complications should the nurse expect?

Hypoglycemia

a nurse is assessing a client who has fluid volume deficit. the nurse should expect which of the following findings? a. decreased Hgb

Increased Bun

A nurse is caring for a client with Cushings syndrome. The nurse should recognize that which of the following are manifestations of cushings syndrome? (SATA)

Moon Face, purple striations, and buffalo hump

a nurse is reviewing discharge instructions with a client following right cataract extraction. which of the following instructions should the nurse include? a. bend at the waist to pick objects up from the floor. b. avoid lifting anything heavier than 4.5 kg (10 lb) for a week c. Sleep on the abdomen to facilitate wound healing. d.

a. bend at the waist to pick objects up from the floor.

8. Sodium polystyrene sulfonate (Kayexalate) is ordered for a patient with hyperkalemia. Before administering the medication, the nurse should assess the a. bowel sounds. b. blood glucose. c. blood urea nitrogen (BUN). d. Level of consciousness (LOC)

a. bowel sounds.

a nurse in a providers office is reviewing lab results for a client who takes furosemide for hypertension. The nurse notes clients potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications? a. cardiac dysrhythmias b. hypoglycemia c. neurogenic shock d. seizures

a. cardiac dysrhythmias

a nurse is caring for a client who is 1 day post op following thyroidectomy. Client reports a tingling sensation in the hands and soles of feet and around lips. what should the nurse assess for? a. chvosteks sign b. babinskis sign c. brudzinskis sign

a. chvosteks sign

a nurse is assessing a client who has diabetes insipidus. Which finding should the nurse expect? a. dehydration b. bradycardia c. polyphagia d. hyperglycemia

a. dehydration

a nurse is planning care for a client with urolithiasis. which of the following actions should the nurse take? a. encourage intake of at least 3 L of fluids per day. b. restrict protein intake for 2 servings per day. c. apply cold compresses to the clients flank area. d. discourage ambulations.

a. encourage intake of at least 3 L of fluids per day.

nurse is caring for a client with type 1 diabetes mellitus that reports feeling shaky and having palpitations. when then nurse finds clients blood glucose to be 48 mg/dl on glucomete, what should the client be given? a. graham crackers b. 1 tsp sugar c. 4 oz diet soda d. 4 oz skim milk

a. graham crackers

a nurse is caring for a client with an indwelling urinary catheter. whihc of the following actions should the nurse take to prevent infection? a. replace the catheter every 3 hours b. irrigate the catheter once every shift c. check the catheter tubing for kinks and twisting d. clean the perineal area with an antiseptic solutions daily.

a. replace the catheter every 3 hours

a nurse is assessing a client that is admitted for elective surgery and a history of addisons disease. which of the following findings should the nurse expect? a.intension tremors b. hirsutism c. hyperpigmentation d. purple striations

c. hyperpigmentation

a nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect? a. hyperactive bowel sounds b. hyperactive reflexes c. extreme thirst d. weak, irregular pulse

d. weak, irregular pulse

nurse is caring for a client with N/V and is receiving IV fluid therapy. Pt BUN is 32 mg/dL, creatinine is 1.1 mg/dL and hematocrit 50%. which nursing intervention is correct?

Evaluate urine for amount and specific gravity

nurse is providing teaching to patient about measures to prevent UTI. Which of the following pt statements indicated a need for further teaching?

I will Need to wipe my perineal area from back to front after urination

nurse is reveiewing the lab report of a client and identifies a serum potassium of 6.8 mEq/L. Which od the following medications should the nurse plan to administer?

Kexalate- Sodium polystryrene

nurse is caring for a client with a lower UTI. Client reports back pain , chills, and malaise. The nurse understand it is necessary to perform costvertebral tenderness assessment to determine the presence of which condition?

Kidney inflammation

a nurse is caring for a client being evaluated for acromegaly. which of the following manifestations should the nurse expect to find? (SATA) a. loss of color discrimination b. coarse facial features c. enlarged distal extremities d. hepatomegaly e. moon face

a. loss of color discrimination b. coarse facial features c. enlarged distal extremities d. hepatomegaly

a nurse is caring for a client in a myxedema coma. which of the follownig actions should the nurse take? a. place the client on aspiration precautions b. turn the client ever 4 hrs. c. initiate measures to cool the client d. check the clients blood pressure every 2 hours.

a. place the client on aspiration precautions

a nurse is assessing a client admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg(12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrualr irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis? a. provide a quiet, low stimulus environment b. administer aspirins as prescribed for any sign of hyperthermia. c. keep the client NPO d. observe the client carefully for signs of hypocalcemia.

a. provide a quiet, low stimulus environment

a nurse is talking with a client that is scheduled for surgery to repair retinal detachment. which of the following preoperative instructions should the nurse include? a. restrict head movement b. eye drops to constrict the pupils will be prescribed c. keep both eyes patched d. apply cool compresses

a. restrict head movement

The priority nursing diagnosis for a patient experiencing an acute attack with Meniere's disease is a. risk for falls related to dizziness. b. impaired verbal communication related to tinnitus. c. self-care deficit (bathing and dressing) related to vertigo. d. imbalanced nutrition: less than body requirements related to nausea.

a. risk for falls related to dizziness.

A nurse is caring for a client who had a total thyroidectomy and a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect? a. tingling of the extremities b. hypoactive deep tendon reflexes c. shortened QT intervals d. constipation

a. tingling of the extremities

a nurse is assessing a client with an acoustic neuroma, which of the following client manifestations should the nurse expect? a. veritgo b. dysphagia c. diplopia d. apraxia

a. veritgo

A nurse is instructing a client with a new diagnosis of hyperparathyroidism, The nurse should include in the instructions that the client is at risk for which of the following complications? a. fluid retention b, pathologic fractures c. impaired skin integrity d. dysphagia

b, pathologic fractures

a nurse is providing instruction to a client with nephrotic syndrome. The nurse should recognize which of the following statements indicates a need for further instructions? a. i should expect my health care provider to prescribe a kidney biopsy. b. I should increase my sodium intake. c. i will lose protein in my urine. d. i can expect to have swelling in my face.

b. I should increase my sodium intake.

Which statement by a patient with bacterial conjunctivitis indicates a need for further teaching? a. I will wash my hands often during the day. b. I will remove my contact lenses at bedtime. c. I will not share towels with my friends or family. d. I will monitor my family for eye redness or drainage.

b. I will remove my contact lenses at bedtime.

Which action can the nurse working in the emergency department delegate to experienced unlicensed assistive personnel (UAP)? a. Ask a patient with decreased visual acuity about medications taken at home. b. Perform Snellen testing of visual acuity for a patient with a history of cataracts. c. Obtain information from a patient about any history of childhood ear infections. d. Inspect a patients external ear for redness, swelling, or presence of skin lesion

b. Perform Snellen testing of visual acuity for a patient with a history of cataracts.

When the patient turns his head quickly during the admission assessment, the nurse observes nystagmus. What is the indicated nursing action? a. Assess the patient with a Rinne test. b. Place a fall-risk bracelet on the patient. c. Ask the patient to watch the mouths of staff when they are speaking. d. Remind unlicensed assistive personnel to speak loudly to the patient

b. Place a fall-risk bracelet on the patient.

A patient who underwent eye surgery is required to wear an eye patch until the scheduled postoperative clinic visit. Which nursing diagnosis will the nurse include in the plan of care? a. Disturbed body image related to eye trauma and eye patch b. Risk for falls related to temporary decrease in stereoscopic vision c. Ineffective health maintenance related to inability to see surroundings d. Ineffective denial related to inability to admit the impact of the eye injury

b. Risk for falls related to temporary decrease in stereoscopic vision

. An 82-year-old patient who is being admitted to the hospital repeatedly asks the nurse to speak up so that I can hear you. Which action should the nurse take? a. Overenunciate while speaking. b. Speak normally but more slowly. c. Increase the volume when speaking. d. Use more facial expressions when talkin

b. Speak normally but more slowly.

Which equipment will the nurse obtain to perform a Rinne test? a. Otoscope b. Tuning fork c. Audiometer d. Ticking watch

b. Tuning fork

a nurse is discussing kidney transplant with a client that has end-stage renal disease (ESRD). which of the following should the nurse identify as a contraindication for the treatments? a. pacemaker b. alcohol use disorder c. 65 years of age d. breast cancer survivor for 8 years

b. alcohol use disorder

nurse is assessing a client who has Graves disease, the nurse should expect which lab results? a. decreased t3 level b. decreased thyroid-stimulating hormone TSH level c. decreased t4 level d. decreased thyroid-stimulating immunoglobins percentage

b. decreased thyroid-stimulating hormone TSH level

a nurse is caring for a client with a new diagnosis of urolithiasis. which of the following should the nurse identify as an associated risk factor? a. hypocalcemia b. family history c. BMI less than 25 d. diuretic use

b. family history

a staff nurse is instructing a client with addisons disease about the disease process. the client asks the nurse what causes addisons disease. which of the following responses should the nurse make? a. it is causes by the overproduction of growth hormones by the pituitary gland. b. it is causes by the lack of production by the adrenal gland. c. it is caused by the lack of production of insulin by the pancreas d. it is causes by the overproduction of parahormone by the parathyroid gland

b. it is causes by the lack of production by the adrenal gland.

nurse is caring for a client that is postoperative following a left corneal transplant. the nurse observes purulent drainage from the affected eye, which of the following is the nurses priority? a. apply a non-pressure patch to the affected eye b. notify the surgeon c. clean eye from inner to outer canthus d. instill an antibiotic solution in both eyes.

b. notify the surgeon

. A female patient with a suspected urinary tract infection (UTI) is to provide a clean-catch urine specimen for culture and sensitivity testing. To obtain the specimen, the nurse will a. have the patient empty the bladder completely, then obtain the next urine specimen that the patient is able to void. b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup. c. insert a short sterile mini catheter attached to a collecting container into the urethra and bladder to obtain the specimen. d. clean the area around the meatus with a povidone-iodine (Betadine) swab, and then have the patient void into a sterile container

b. teach the patient to clean the urethral area, void a small amount into the toilet, and then void into a sterile specimen cup.

To decrease the risk for future hearing loss, which action should the nurse who is working with college students at the on-campus health clinic implement? a. Arrange to include otoscopic examinations for all patients. b. Administer influenza immunizations to all students at the clinic. c. Discuss the importance of limiting exposure to amplified music. d. Perform tympanometry on all patients between the ages of 18 to 24

c. Discuss the importance of limiting exposure to amplified music.

A 65-year-old patient is being evaluated for glaucoma. Which information given by the patient has implications for the patients treatment? a. I use aspirin when I have a sinus headache. b. I have had frequent episodes of conjunctivitis. c. I take metoprolol (Lopressor) daily for angina. d. I have not had an eye examination for 10 year

c. I take metoprolol (Lopressor) daily for angina.

a nurse is developing a plan of care for a client that is to begin receiving peritoneal dialysis. Which of the following interventions should the nurse implement to ensure proper dialysate exchange? a. maintain the client in a left lateral position during dialysis b. place the drainage bag above the level of the clients abdomen, c. Warm the dialysate solution prior to instillation. d. monitor vital signs every 2 hr during the procedure.

c. Warm the dialysate solution prior to instillation.

The charge nurse must intervene immediately if observing a nurse who is caring for a patient with vestibular disease a. speaking slowly to the patient. b. facing the patient directly when speaking. c. encouraging the patient to ambulate independently. d. administering Rinne and Weber tests to the patient

c. encouraging the patient to ambulate independently.

a nurse is instructing about disease management for a client with type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the instructions? a. insulin allows me to eat ice cream at bedtime b. i am to take my blood sugar readings after meals c. i give the insulin injections in my abdominal area. d. a weight reduction program will make me hypoglycemic.

c. i give the insulin injections in my abdominal area.

nurse is caring for a client scheduled for cataract extraction and the implantation of an intraocular lens. what information is most important for the nurse to report to the health care provider? a. the client reports blurred vision for 3 years b. the client takes 2 anti-hypertensive medications daily. c. the client gets nauseated with general anesthesia. d. the client has been NPO for 8 hours.

c. the client gets nauseated with general anesthesia.

a nurse is providing discharge teaching to a female client who has neuropathy and a new prescription for gabapentin. which of the following statements should the nurse include in teaching? a. take this medication with an antacid to reduce gastric irritation. b. you should take this medication with meals c. you may experience drowsiness while taking this medication d you may continue to breastfeed while taking this medication.

c. you may experience drowsiness while taking this medication

nurse is planning care for a client who is postop following thyroidectomy. which interventions should the nurse include in the plan?

check clients voice every 2 hours

a home health nurse is assessing an older adult in the home who has decreased vision due to history of glaucoma. which of the following findings should the nurse identify as a safety risk? a. uses a microwave for cooking b. handrails are present in the bathroom c. electrical cords are placed along the walls d. scatter rugs are present in the kitchen

d. scatter rugs are present in the kitchen