PNE 162 Final--NCLEX

The nurse is teaching the client to administer enoxaparin (Lovenox) following a total hip arthroplasty? The nurse should instruct the client about which of the following? Select all that apply. 1. Report promptly any difficulty breathing, rash, or itching. 2. Notify the health care provider of unusual bruising. 3. Avoid all aspirin-containing medications. 4. Wear or carry medical identification. 5. Expel the air bubble from the syringe before the injection. 6. Remove needle immediately after medication is injected.

1, 2, 3, 4. Client/ family teaching should include advising the client to report any symptoms of unusual bleeding or bruising, dizziness, itching, rash, fever, swelling, or difficulty breathing to healthcare provider immediately. Instruct the client not to take aspirin or nonsteroidal anti-inflammatory drugs without consulting health care provider while on therapy. A low-molecular weight heparin is considered to be a high-risk medication and the client should wear or carry medical identification. The air bubble should not be expelled from the syringe because the bubble insures the client receives the full dose of the medication. The client should allow 5 seconds to pass before withdrawing the needle to prevent seepage of the medication out of the site.

The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal findings? Select all that apply. 1. Reduced edema of the left knee. 2. Skin warm to touch. 3. Capillary refill response. 4. Moves toes. 5. Pain absent. 6. Pulse on left leg weaker than right leg.

1, 2, 3, 4. Postoperatively, the knee in a total knee replacement is dressed with a compression bandage and ice may be applied to control edema and bleeding. Recurrent assessment by the nurse for neurovascular changes can prevent loss of limb. Normal neurovascular findings include: color normal, extremity warm, capillary refill less than 3 seconds, moderate edema, tissue not palpably tense, pain controllable, normal sensations, no paresthesia, normal motor abilities, no paresis or paralysis, and pulses strong and equal.

The nurse is assessing a client who had a left hip replacement 36 hours ago. Which of the following indicates the prosthesis is dislocated? Select all that apply. 1. The client reported a "popping" sensation in the hip. 2. The left leg is shorter than the right leg. 3. The client has sharp pain in the groin. 4. The client cannot move his right leg. 5. The client

1, 2, 3. Dislocation of a hip prosthesis may occur with positioning that exceeds the limits of the prosthesis. The nurse must recognize dislocation of the prosthesis. Signs of prosthesis dislocation include: acute groin pain in the affected hip, shortening of the affected leg, restricted ability or inability to move the affected leg, and reported "popping" sensation in the hip. Toe wiggling is not a test for potential hip dislocation.

The nurse is preparing the discharge of a client who has had a knee replacement with a metal joint. The nurse should instruct the client about which of the following? Select all that apply. 1. Notify health care providers about the joint prior to invasive procedures. 2. Avoid use of Magnetic Resonance Imaging (MRI) scans. 3. Notify airport security that the joint may set off alarms on metal detectors. 4. Refrain from carrying items weighing more than 5 lb. 5. Limit fluid intake to 1,000 mL/ day.

1, 2, 3. The nurse should instruct the client to notify the dentist and other health care providers of the need to take prophylactic antibiotics if undergoing any procedure (e.g., tooth extraction) due to the potential of bacteremia. The nurse should also advise the client that the metal components of the joint may set off the metal-detector alarms in airports. The client should also avoid MRI studies because the implanted metal components will be pulled toward the large magnet core of the MRI. Any weight bearing that is permitted is prescribed by the orthopedic surgeon and is usually not limited to 5 lb. Post surgery, the client can resume a normal diet with regular fluid intake.

A client is to have a total hip replacement. The preoperative plan should include which of the following? Select all that apply. 1. Administer antibiotics as prescribed to ensure therapeutic blood levels. 2. Apply leg compression device. 3. Request a trapeze be added to the bed. 4. Teach isometric exercises of quadriceps and gluteal muscles. 5. Demonstrate crutch walking with a 3-point gait. 6. Place Buck's traction on the bed.

1, 3, 4. Administration of antibiotics as prescribed will aid in the acquisition of therapeutic blood levels during and immediately after surgery to prevent osteomyelitis. The nurse can request that a trapeze be added to the bed so the client can assist with lifting and turning. The nurse should also demonstrate and have the client practice isometric exercises (muscle setting) of quadriceps and gluteal muscles. The client will not use crutches after surgery; a physical therapy assistant will initially assist the client with walking by using a walker. The client will not use Buck's traction. The client will require anti-embolism stockings and use of a leg compression device to minimize the risk of thrombus formation and potential emboli; the leg compression device is applied during surgery and maintained per physician order.

When preparing a client for discharge from the hospital after a total knee replacement, the nurse should include which of the following information in the discharge plan? Select all that apply. 1. Report signs of infection to health care provider. 2. Keep the affected leg and foot on the floor when sitting in a chair. 3. Remove anti-embolism stockings when sleeping. 4. The physical therapist will encourage progressive ambulation with use of assistive devices. 5. Change the dressing daily.

1, 4. After a total knee replacement, efforts are directed at preventing complications, such as thromboembolism, infection, limited range of motion, and peroneal nerve palsy. The nurse should instruct the client to report signs of infection, such as an increased temperature. To prevent edema, the affected leg must remain elevated when the client sits in a chair. After discharge, the client may undergo physical therapy on an outpatient basis per physician order. The client should leave the dressing in place until the follow-up visit with the surgeon.

A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome? 1. The client drinks 2,000 mL of fluid per day. 2. The client understands how to manage the incision. 3. The client's bed linens are changed as needed. 4. The client's skin remains cool throughout hospitalization.

1. An average adult requires approximately 1,100- 1,400 mL of fluids per day. In some instances, such as when a person has an increase in body temperature or has increased perspiration, additional water may be necessary. With an increase in body temperature, there is also an increase in insensible fluid loss. The increased loss of fluid causes an increased need for fluid replacement. If the loss is significant and/ or goes untreated, an individual's intake will not be balanced with output. Managing the incision, changing the bed linens, or keeping the client's skin cool are not outcomes indicative of resolution of a fluid volume deficit.

Which of the following should the nurse include in the teaching plan for a client with arterial insufficiency to the feet that is being managed conservatively? 1. Daily lubrication of the feet. 2. Soaking the feet in warm water. 3. Applying antiembolism stockings. 4. Wearing firm, supportive leather shoes.

1. Daily lubrication, inspection, cleaning, and patting dry of the feet should be performed to prevent cracking of the skin and possible infection. Soaking the feet in warm water should be avoided because soaking can lead to maceration and subsequent skin breakdown. Additionally, the client with arterial insufficiency typically experiences sensory changes, so the client may be unable to detect water that is too warm, thus placing the client at risk for burns. Antiembolism stockings, appropriate for clients with venous insufficiency, are inappropriate for clients with arterial insufficiency and could lead to a worsening of the condition. Footwear should be roomy, soft, and protective and allow air to circulate. Therefore, firm, supportive leather shoes would be inappropriate.

Following a total joint replacement, which of the following complications has the greatest likelihood of occurring? 1. Deep vein thrombosis (DVT). 2. Polyuria. 3. Intussception of the bowel. 4. Wound evisceration.

1. Deep vein thrombosis is a complication of total joint replacement and may occur during hospitalization or develop later when the client is home. Clients who are obese or have previous history of a DVT or PE are at high risk. Immobility produces venous stasis, increasing the client's chance to develop a venous thromboembolism. Signs of a DVT include: unilateral calf tenderness, warmth, redness, and edema (increased calf circumference). Findings should be reported promptly to the physician for definitive evaluation and therapy. Polyuria may be indicative of diabetes mellitus. Intussusception of the bowel and wound evisceration tend to occur after abdominal surgeries.

The client has just had a total knee replacement for severe osteoarthritis. Which of the following assessment findings should lead the nurse to suspect possible nerve damage? 1. Numbness. 2. Bleeding. 3. Dislocation. 4. Pinkness.

1. The nurse should suspect nerve damage if numbness is present. However, whether the damage is short-term and related to edema or long-term and related to permanent nerve damage would not be clear at this point. The nurse needs to continue to assess the client's neurovascular status, including pain, pallor, pulselessness, paresthesia, and paralysis (the five P's). Bleeding would suggest vascular damage or hemorrhage. Dislocation would suggest malalignment. Pink color would suggest adequate circulation to the area. Numbness would suggest neurologic damage.

Following a total hip replacement, the nurse should do which of the following? Select all that apply. 1. With the aid of a coworker, turn the client from the supine to the prone position every 2 hours. 2. Encourage the client to use the overhead trapeze to assist with position changes. 3. For meals, elevate the head of the bed to 90 degrees. 4. Use a fracture bedpan when needed by the client. 5. When the client is in bed, prevent thromboembolism by encouraging the client to do toe-pointing exercises.

2, 4, 5. Following total hip replacement, the client should use the overhead trapeze to assist with position changes. The head of the bed should not be elevated more than 45 degrees; any height greater than 45 degrees puts a strain on the hip joint and may cause dislocation. To use a fracture bedpan, instruct the client to flex the unoperated hip and knee to lift buttocks onto pan. Toe-pointing exercises stimulate circulation in the lower extremities to prevent the formation of thrombi and potential emboli. The prone position is avoided shortly after a total hip replacement.

A client says, "I hate the idea of being an invalid after they cut off my leg." Which of the following would be the nurse's most therapeutic response? 1. "At least you will still have one good leg to use." 2. "Tell me more about how you're feeling." 3. "Let's finish the preoperative teaching." 4. "You're lucky to have a wife to care for you."

2. Encouraging the client who will be undergoing amputation to verbalize his feelings is the most therapeutic response. Asking the client to tell more about how he is feeling helps to elicit information, providing insight into his view of the situation and also providing the nurse with ideas to help him cope. The nurse should avoid value-laden responses, such as, "At least you will still have one good leg to use," that may make the client feel guilty or hostile, thereby blocking further communication. Furthermore, stating that the client still has one good leg ignores his expressed concerns. The client has verbalized feelings of helplessness by using the term "invalid." The nurse needs to focus on this concern and not try to complete the teaching first before discussing what is on the client's mind. The client's needs, not the nurse's needs, must be met first. It is inappropriate for the nurse to assume to know the relationship between the client and his wife or the roles they now must assume as dependent client and caregiver. Additionally, the response about the client's wife caring for him may reinforce the client's feelings of helplessness as an invalid.

The client with peripheral arterial disease says, "I've really tried to manage my condition well." Which of the following should the nurse determine as appropriate for this client? 1. Resting with the legs elevated above the level of the heart. 2. Walking slowly but steadily for 30 minutes twice a day. 3. Minimizing activity as much and as often as possible. 4. Wearing antiembolism stockings at all times when out of bed.

2. Slow, steady walking is a recommended activity for the client with peripheral arterial disease because it stimulates the development of collateral circulation needed to ensure adequate tissue oxygenation. The client with peripheral arterial disease should not minimize activity. Activity is necessary to foster the development of collateral circulation. Elevating the legs above the heart is an appropriate strategy for reducing venous congestion. Wearing antiembolism stockings promotes the return of venous circulation, which is important for clients with venous insufficiency. However, their use in clients with peripheral arterial disease may cause the disease to worsen.

A client has severe arterial occlusive disease and gangrene of the left great toe. Which of the following findings is expected? 1. Edema around the ankle. 2. Loss of hair on the lower leg. 3. Thin, soft toenails. 4. Warmth in the foot.

2. The client with severe arterial occlusive disease and gangrene of the left great toe would have lost the hair on the leg due to decreased circulation to the skin. Edema around the ankle and lower leg would indicate venous insufficiency of the lower extremity. Thin, soft toenails (i.e., not thickened and brittle) are a normal finding. Warmth in the foot indicates adequate circulation to the extremity. Typically, the foot would be cool to cold if a severe arterial occlusion were present.

The client asks the nurse, "Why can't the physician tell me exactly how much of my leg he's going to take off? Don't you think I should know that?" On which of the following should the nurse base the response? 1. The need to remove as much of the leg as possible. 2. The adequacy of the blood supply to the tissues. 3. The ease with which a prosthesis can be fitted. 4. The client's ability to walk with a prosthesis.

2. The level of amputation often cannot be accurately determined until during surgery, when the surgeon can directly assess the adequacy of the circulation of the residual limb. From a moral, ethical, and legal viewpoint, the surgeon attempts to remove as little of the leg as possible. Although a longer residual limb facilitates prosthesis fitting, unless the stump is receiving a good blood supply the prosthesis will not function properly because tissue necrosis will occur. Although the client's ability to walk with a prosthesis is important, it is not a determining factor in the decision about the level of amputation required. Blood supply to the tissue is the primary determinant.

A client who had a total hip replacement 4 days ago is worried about dislocation of the prosthesis. The nurse should respond by saying which of the following? 1. "Don't worry. Your new hip is very strong." 2. "Use of a cushioned toilet seat helps to prevent dislocation." 3. "Activities that tend to cause adduction of the hip tend to cause dislocation, so try to avoid them." 4. "Decreasing use of the abductor pillow will strengthen the muscles to prevent dislocation."

3. Dislocation precautions include: avoid extremes of internal rotation, adduction, and 90-degree flexion of affected hip for at least 4 to 6 weeks after the procedure. Use of an abduction pillow prevents adduction. Decreasing use of the abductor pillow does not strengthen the muscles to prevent dislocation. Informing a client to "not worry" is not therapeutic. A cushioned toilet seat does not prevent hip dislocation.

The nurse has established a goal with a client to improve mobility following hip replacement. Which of the following is a realistic outcome at the time of discharge from the surgical unit? 1. The client can walk throughout the entire hospital with a walker. 2. The client can walk the length of a hospital hallway with minimal pain. 3. The client has increased independence in transfers from bed to chair. 4. The client can raise the affected leg 6 inches with assistance.

3. Expected outcomes at the time of discharge from the surgical unit after a hip replacement include the following: increased independence in transfers, participates in progressive ambulation without pain or assistance, and raises the affected leg without assistance. The client will not be able to walk throughout the hospital, walk for a distance without some postoperative pain, or raise the affected leg more than several inches. The client may be referred to a rehabilitation unit in order to achieve the additional independence, strength, and pain relief.

The nurse is planning care for a group of clients who have had total hip replacement. Of the clients listed below, which is at highest risk for infection and should be assessed first? 1. A 55-year-old client who is 6 feet tall and weighs 180 lb. 2. A 90-year-old who lives alone. 3. A 74-year-old who has periodontal disease with periodontitis. 4. A 75-year-old who has asthma and uses an inhaler.

3. Infection is a serious complication of total hip replacement and may necessitate removal of the implant. Clients who are obese, poorly nourished, elderly, have poorly controlled diabetes, rheumatoid arthritis, or concurrent infections (e.g., dental, urinary tract) are at high risk for infection. Clients who are of normal weight and have well-controlled chronic diseases are not at risk for infection. Living alone is not a risk factor for infection.

A client with absent peripheral pulses and pain at rest is scheduled for an arterial Doppler study of the affected extremity. When preparing the client for this test, the nurse should: 1. Have the client sign a consent form for the procedure. 2. Administer a pretest sedative as appropriate. 3. Keep the client tobacco-free for 30 minutes before the test. 4. Wrap the client's affected foot with a blanket.

3. The client should be tobacco-free for 30 minutes before the test to avoid false readings related to the vasoconstrictive effects of smoking on the arteries. Because this test is noninvasive, the client does not need to sign a consent form. The client should receive an opioid analgesic, not a sedative, to control the pain as the blood pressure cuffs are inflated during the Doppler studies to determine the ankle-to-brachial pressure index. The client's ankle should not be covered with a blanket because the weight of the blanket on the ischemic foot will cause pain. A bed cradle should be used to keep even the weight of a sheet off the affected foot.

After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following? 1. A developing infection. 2. Bleeding in the operative site. 3. Joint dislocation. 4. Glue seepage into soft tissue.

3. The joint has dislocated when the client with a total joint prosthesis develops severe sudden pain and an inability to move the extremity. Clinical manifestations of an infection would include inflammation, redness, erythema, and possibly drainage and separation of the wound. Bleeding could be external (e.g., blood visible from the wound or on the dressing) or internal and manifested by signs of shock (e.g., pallor, coolness, hypotension, tachycardia). The seepage of glue into soft tissue would have occurred in the operating room, when the glue is still in the liquid form. The glue dries into the hard, fixed form before the wound is closed.

Which of the following should the nurse identify as the least likely factor contributing to a client's peripheral vascular disease? 1. Uncontrolled diabetes mellitus for 15 years. 2. A 20-pack-year history of cigarette smoking. 3. Current age of 39 years. 4. A serum cholesterol concentration of 275 mg/ dL.

3. Typically, peripheral vascular disease is considered to be a disorder affecting older adults. Therefore, an age of 39 years would not be considered as a risk factor contributing to the development of peripheral vascular disease. Uncontrolled diabetes mellitus is considered a risk factor for peripheral vascular disease because of the macroangiopathic and microangiopathic changes that result from poor blood glucose control. Cigarette smoking is a known risk factor for peripheral vascular disease. Nicotine is a potent vasoconstrictor. Serum cholesterol levels greater than 200 mg/ dL are considered a risk factor for peripheral vascular disease.

In preparation for total knee surgery, a 200-lb client with osteoarthritis must lose weight. Which of the following exercises should the nurse recommend as best if the client has no contraindications? 1. Weight lifting. 2. Walking. 3. Aquatic exercise. 4. Tai chi exercise.

3. When combined with a weight loss program, aquatic exercise would be best because it cushions the joints and allows the client to burn off calories. Aquatic exercise promotes circulation, muscle toning, and lung expansion, which promote healthy preoperative conditioning. Weight lifting and walking are too stressful to the joints, possibly exacerbating the client's osteoarthritis. Although tai chi exercise is designed for stretching and coordination, it would not be the best exercise for this client to help with weight loss.

After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following? 1. Elevate the sequential compression device (SCD) on two pillows. 2. Change the settings on the SCD to make the client more comfortable. 3. Stop the SCD to remove dressings and bathe the leg. 4. Discontinue the SCD when the client is ambulatory.

4. After knee arthroplasty, the knee will be extended and immobilized with a firm compression dressing and an adjustable soft extension splint in place. A sequential compression device (SCD) will be applied. The SCD can be discontinued when the client is ambulatory, but while the client is in bed the SCD needs to be maintained to prevent thromboembolism. The SCD should be positioned on the bed, but not on two pillows. Settings for the SCD are ordered by the orthopedic surgeon. Initial dressing changes are completed by the orthopedic surgeon and changed as needed per physician order.

Following a total hip replacement, the nurse should position the client in which of the following ways? 1. Place weights alongside of the affected extremity to keep the extremity from rotating. 2. Elevate both feet on two pillows. 3. Keep the lower extremities adducted by use of an immobilization binder around both legs. 4. Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.

4. After total hip replacement, proper positioning by the nurse prevents dislocation of the prosthesis. The nurse should place the client in a supine position and keep the affected extremity in slight abduction using an abduction splint or pillows or Buck's extension traction. The client must not abduct or flex the operated hip because this may produce dislocation.

1. The nurse is aware that the patient who is to have his leg amputated is also to have a prosthesis fitted in the OR at the same time. The preoperative teaching plan will include the fact that there will be: 1. the need for extra preoperative medications. 2. a rigid dressing applied to accommodate the prosthesis. 3. a series of temporary prostheses before the permanent one is put in place. 4. the need to "wire" the residual limb for acceptance of the prosthesis.

ANS: 2 There will be a rigid dressing applied to the residual limb to accommodate the prosthesis immediately after surgery.

The client is to be discharged on a low-fat, low-cholesterol, low-sodium diet. Which of the following should be the nurse's first step in planning the dietary instructions? 1. Determining the client's knowledge level about cholesterol. 2. Asking the client to name foods that are high in fat, cholesterol, and salt. 3. Explaining the importance of complying with the diet. 4. Assessing the client's and family's typical food preferences.

4. Before beginning dietary instructions and interventions, the nurse must first assess the client's and family's food preferences, such as pattern of food intake, life style, food preferences, and ethnic, cultural, and financial influences. Once this information is obtained, the nurse can begin teaching based on the client's current knowledge level and then building on this knowledge base.

Prior to surgery, the nurse is instructing a client who will have a total hip replacement tomorrow. Which of the following information is most important to include in the teaching plan at this time? 1. Teaching how to prevent hip flexion. 2. Demonstrating coughing and deep-breathing techniques. 3. Showing the client what an actual hip prosthesis looks like. 4. Assessing the client's fears about the procedure.

4. Before implementing a teaching plan, the nurse should determine the client's fears about the procedure. Only then can the client begin to hear what the nurse has to share about the individualized teaching plan designed to meet the client's needs. In the preoperative period, the client needs to learn how to correctly prevent hip flexion and to demonstrate coughing and deep breathing. However, this teaching can be effective only after the client's fears have been assessed and addressed. Although the client may appreciate seeing what a hip prosthesis looks like, so as to understand the new body part, this is not a necessity.

A client who has had a total hip replacement has a dislocated hip prosthesis. The nurse should first? 1. Stabilize the leg with Buck's traction. 2. Apply an ice pack to the affected hip. 3. Position the client toward the opposite side of the hip. 4. Notify the orthopedic surgeon.

4. If a prosthesis becomes dislocated, the nurse should immediately notify the surgeon. This is done so the hip can be reduced and stabilized promptly to prevent nerve damage and to maintain circulation. After closed reduction, the hip may be stabilized with Buck's traction or a brace to prevent recurrent dislocation. If ordered by the surgeon, an ice pack may be applied post reduction to limit edema, although caution must be utilized due to potential muscle spasms. Some orthopedic surgeons may order the client be turned toward the side of the reduced hip but that is not the nurse's first response.

On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following? 1. Encourage the client to apply full weight-bearing. 2. Order a walker for the client. 3. Place a straight-backed chair at the foot of the bed. 4. Apply a knee immobilizer.

4. The knee is usually protected with a knee immobilizer (splint, cast, or brace) and is elevated when the client sits in a chair. Pre- and post-surgery, the physician prescribes weight-bearing limits and use of assistive devices for progressive ambulation. Positioning a straight-backed chair at the foot of the bed is not an action conducive for getting the client out of bed on the evening of surgery for a total knee replacement.

A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first? 1. Tell the client it is impossible to feel the pain. 2. Show the client that the toes are not there. 3. Explain to the client that her pain is real. 4. Give the client the prescribed opioid analgesic.

4. The nurse's first action should be to administer the prescribed opioid analgesic to the client, because this phenomenon is phantom sensation and interventions should be provided to relieve it. Pain relief is the priority. Phantom sensation is a real sensation. It is incorrect and inappropriate to tell a client that it is impossible to feel the pain. Although it does relieve the client's apprehensions to be told that phantom sensations are a real phenomenon, the client needs prompt treatment to relieve the pain sensation. Usually phantom sensation will go away. However, showing the client that the toes are not there does nothing to provide the client with relief.

A client who has had an above-the-knee amputation develops a dime-sized bright red spot on the dressing after 45 minutes in the postanesthesia recovery unit. The nurse should: 1. Elevate the stump. 2. Reinforce the dressing. 3. Call the surgeon. 4. Draw a mark around the site.

4. The priority action is to draw a mark around the site of bleeding to determine the rate of bleeding. Once the area is marked, the nurse can determine whether the bleeding is increasing or decreasing by the size of the area marked. Because the spot is bright red, the bleeding is most likely arterial in origin. Once the rate and source of bleeding are identified, the surgeon should be notified. The stump is not elevated because adhesions may occur, interfering with the ability to fit a prosthesis. The dressing would be reinforced if the bleeding is determined to be of venous origin, characterized by slow oozing of darker blood that ceases with the application of a pressure dressing. Typically, operative dressings are not changed for 24 hours. Therefore, the dressing is reinforced to prevent organisms from penetrating through the blood-soaked areas of the initial postoperative dressing.

1. A patient is 1 day postsurgery for a crushed pelvis. The CNA reports that the patient is complaining of being short of breath and demonstrating signs of confusion and restlessness. The nurse suspects from these signs alone that the patient has suffered: 1. impending shock. 2. a fat embolus. 3. anxiety. 4. neurovascular compromise.

ANS: 2 These are the classic symptoms of a fat embolus that has escaped from the crushed marrow.

The client with an above-the-knee amputation is to use crutches while his prosthesis is being adjusted. In which of the following exercises should the nurse instruct the client to best prepare him for using crutches? 1. Abdominal exercises. 2. Isometric shoulder exercises. 3. Quadriceps setting exercises. 4. Triceps stretching exercises.

4. Use of crutches requires significant strength from the triceps muscles. Therefore, efforts are focused on strengthening these muscles in anticipation of crutch walking. Bed and wheelchair push-ups are excellent exercises targeted at the triceps muscles. Abdominal exercises, range-of-motion and isometric exercises of the shoulders, and quadriceps and gluteal setting exercises are not helpful in preparing for crutch walking.

The nurse teaches a client about using the crutches, instructing the client to support her weight primarily on which of the following body areas? 1. Axillae. 2. Elbows. 3. Upper arms. 4. Hands.

4. When using crutches, the client is taught to support her weight primarily on the hands. Supporting body weight on the axillae, elbows, or upper arms must be avoided to prevent nerve damage from excessive pressure.

22. The nurse reminds the patient with a below-knee amputation that to prevent the loss of calcium and protein, the patient should: 1. drink 1 to 2 liters of fluid daily. 2. ingest at least four milk products each day. 3. ambulate 30 minutes a day. 4. take vitamin supplements daily.

ANS: 3 Even a small amount of ambulation will decrease the loss of calcium and protein.

21. A 63-year-old patient is newly diagnosed with type 2 diabetes. When developing an education plan, the nurse's first action should be to a. assess the patient's perception of what it means to have type 2 diabetes. b. demonstrate how to check glucose using capillary blood glucose monitoring. c. ask the patient's family to participate in the diabetes education program. d. discuss the need for the patient to actively participate in diabetes management.

A Rationale: Before planning education, the nurse should assess the patient's interest in and ability to self-manage the diabetes. After assessing the patient, the other nursing actions may be appropriate, but planning needs to be individualized to each patient. Cognitive Level: Application Text Reference: p.1264 Nursing Process: Planning NCLEX: Health Promotion and Maintenance

18. A patient with type 2 diabetes that is controlled with diet and metformin (Glucophage) also has severe rheumatoid arthritis (RA). During an acute exacerbation of the patient's arthritis, the health care provider prescribes prednisone (Deltasone) to control inflammation. The nurse will anticipate that the patient may a. require administration of insulin while taking prednisone. b. develop acute hypoglycemia during the RA exacerbation. c. have rashes caused by metformin-prednisone interactions. d. need a diet higher in calories while receiving prednisone.

A Rationale: Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a complication of RA exacerbation or prednisone use. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient is likely to have an increased appetite when taking prednisone, but it will be important to avoid weight gain for the patient with RA. Cognitive Level: Application Text Reference: pp. 1258, 1267 Nursing Process: Planning NCLEX: Physiological Integrity

36. After the home health nurse has taught a patient and family about how to use glargine and regular insulin safely, which action by the patient indicates that the teaching has been successful? a. The patient disposes of the open insulin vials after 4 weeks. b. The patient draws up the regular insulin in the syringe and then draws up the glargine. c. The patient stores extra vials of both types of insulin in the freezer until needed. d. The patient's family prefills the syringes weekly and stores them in the refrigerator.

A Rationale: Insulin can be stored at room temperature for 4 weeks. Glargine should not be mixed with other insulins or prefilled and stored. Freezing alters the insulin molecule and should not be done. Cognitive Level: Application Text Reference: p. 1261 Nursing Process: Evaluation NCLEX: Physiological Integrity

14. A patient using a split mixed-dose insulin regimen asks the nurse about the use of intensive insulin therapy to achieve tighter glucose control. The nurse should teach the patient that a. intensive insulin therapy requires three or more injections a day in addition to an injection of a basal long-acting insulin. b. intensive insulin therapy is indicated only for newly diagnosed type 1 diabetics who have never experienced ketoacidosis. c. studies have shown that intensive insulin therapy is most effective in preventing the macrovascular complications characteristic of type 2 diabetes. d. an insulin pump provides the best glucose control and requires about the same amount of attention as intensive insulin therapy.

A Rationale: Patients using intensive insulin therapy must check their glucose level four to six times daily and administer insulin accordingly. A previous episode of ketoacidosis is not a contraindication for intensive insulin therapy. Intensive insulin therapy is not confined to type 2 diabetics and would prevent microvascular changes as well as macrovascular changes. Intensive insulin therapy and an insulin pump are comparable in glucose control. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Implementation NCLEX: Physiological Integrity

8. The patient with peripheral vascular disease and diabetes asks what he can do to help prevent an amputation. The nurse is quick to respond: 1. "There is really not anything you can do to help." 2. "Stopping smoking would help prevent vasoconstriction." 3. "You will not need to check your blood glucose levels." 4. "It is important to eat big meals so your body can heal."

ANS: 2 Smoking cessation is a huge step in maintaining healthy tissue.

28. Intramuscular glucagon is administered to an unresponsive patient for treatment of hypoglycemia. Which action should the nurse take after the patient regains consciousness? a. Give the patient a snack of cheese and crackers. b. Have the patient drink a glass of orange juice or nonfat milk. c. Administer a continuous infusion of 5% dextrose for 24 hours. d. Assess the patient for symptoms of hyperglycemia.

A Rationale: Rebound hypoglycemia can occur after glucagon administration, but having a meal containing complex carbohydrates plus protein and fat will help prevent hypoglycemia. Orange juice and nonfat milk will elevate blood sugar rapidly, but the cheese and crackers will stabilize blood sugar. Administration of glucose intravenously might be used in patients who were unable to take in nutrition orally. The patient should be assessed for symptoms of hypoglycemia after glucagon administration. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity

11. The nurse has been teaching the patient to administer a dose of 10 units of regular insulin and 28 units of NPH insulin. The statement by the patient that indicates a need for additional instruction is, a. "I need to rotate injection sites among my arms, legs, and abdomen each day." b. "I will 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 I inject the insulin."

A Rationale: Rotating sites is no longer necessary because all insulin is now purified human insulin, and the risk for lipodystrophy is low. The other patient statements are accurate and indicate that no additional instruction is needed. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

22. Cardiac monitoring is initiated for a patient in diabetic ketoacidosis (DKA). The nurse recognizes that this measure is important to identify a. electrocardiographic (ECG) changes and dysrhythmias related to hypokalemia. b. fluid overload resulting from aggressive fluid replacement. c. the presence of hypovolemic shock related to osmotic diuresis. d. cardiovascular collapse resulting from the effects of hyperglycemia.

A Rationale: The hypokalemia associated with metabolic acidosis can lead to potentially fatal dysrhythmias such as ventricular tachycardia and ventricular fibrillation, which would be detected with ECG monitoring. Fluid overload, hypovolemia, and cardiovascular collapse are possible complications of DKA, but cardiac monitoring would not detect theses. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity

20. A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. During evaluation of the patient's technique of SMBG, the nurse identifies a need for additional teaching when the patient a. chooses a puncture site in the center of the finger pad. b. washes the puncture site using soap and water. c. says the result of 130 mg indicates good blood sugar control. d. hangs the arm down for a minute before puncturing the site.

A Rationale: The patient is taught to choose a puncture site at the side of the finger pad. The other patient actions indicate that teaching has been effective. Cognitive Level: Application Text Reference: p. 1270 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

17. When teaching a patient with type 2 diabetes about taking glipizide (Glucotrol), the nurse determines that additional teaching about the medication is needed when the patient says, a. "Since I can take oral drugs rather than insulin, my diabetes is not serious and won't cause many complications." b. "If I overeat at a meal, I will still take just the usual dose of medication." c. "If I become ill, I may have to take insulin to control my blood sugar." d. "I should check with my doctor before taking any other medications because there are many that will affect glucose levels."

A Rationale: The patient should understand that type 2 diabetes places the patient at risk for many complications and that good glucose control is as important when taking oral agents as when using insulin. The other statements are accurate and indicate good understanding of the use of glipizide. Cognitive Level: Application Text Reference: p. 1275 Nursing Process: Evaluation NCLEX: Health Promotion and Maintenance

26. While hospitalized and recovering from an episode of diabetic ketoacidosis, the patient calls the nurse and reports feeling anxious, nervous, and sweaty. Based on the patient's report, the nurse should a. obtain a glucose reading using a finger stick. b. administer 1 mg glucagon subcutaneously. c. have the patient eat a candy bar. d. have the patient drink 4 ounces of orange juice.

A Rationale: The patient's clinical manifestations are consistent with hypoglycemia and the initial action should be to check the patient's glucose with a finger stick or order a stat blood glucose. If the glucose is low, the patient should ingest a rapid-acting carbohydrate, such as orange juice. Glucagon might be given if the patient's symptoms become worse or if the patient is unconscious. Candy bars contain fat, which would slow down the absorption of sugar and delay the response to treatment. Cognitive Level: Application Text Reference: p. 1282 Nursing Process: Implementation NCLEX: Physiological Integrity

16. Glyburide (Micronase, DiaBeta, Glynase) is prescribed for a patient whose type 2 diabetes has not been controlled with diet and exercise. When teaching the patient about glyburide, the nurse explains that a. glyburide stimulates insulin production and release from the pancreas. b. the patient should not take glyburide for 48 hours after receiving IV contrast media. c. glyburide should be taken even when the blood glucose level is low in the morning. d. glyburide decreases glucagon secretion.

A Rationale: The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, since hypoglycemia can occur with this category of medication. Metformin should be held for 48 hours after administration of IV contract, but this is not necessary for glyburide. Cognitive Level: Application Text Reference: pp. 1265-1266 Nursing Process: Implementation NCLEX: Physiological Integrity

11. The patient who had a below-knee amputation 3 days ago is complaining of burning pain in his left foot. The nurse should: 1. remind the patient that it is only phantom pain. 2. medicate patient with the ordered pain remedy. 3. remind him that such sensations will go away in a few weeks. 4. distract the patient with conversation.

ANS: 2 The nurse should medicate a patient who is complaining. Phantom pain is real.

17. Because of the anticoagulant in the saliva of leeches, they are used to treat which of the following in the replantation patient? 1. inadequate arterial blood flow 2. venous insufficiency 3. venous congestion 4. increased arterial blood flow

ANS: 3 Leeches are used for venous congestion.

32. Amitriptyline (Elavil) is prescribed for a diabetic patient with peripheral neuropathy who has burning foot pain occurring mostly at night. Which information should the nurse include when teaching the patient about the new medication? a. Amitriptyline will help prevent the transmission of pain impulses to the brain. b. Amitriptyline will improve sleep and make you less aware of nighttime pain. c. Amitriptyline will decrease the depression caused by the pain. d. Amitriptyline will correct some of the blood vessel changes that cause pain.

A Rationale: Tricyclic antidepressants decrease the transmission of pain impulses to the spinal cord and brain. Tricyclics also improve sleep quality and are used for depression, but that is not the major purpose for their use in diabetic neuropathy. The blood vessel changes that contribute to neuropathy are not affected by tricyclics. Cognitive Level: Application Text Reference: p. 1285 Nursing Process: Implementation NCLEX: Physiological Integrity

5. When assessing the patient experiencing the onset of symptoms of type 1 diabetes, which question should the nurse ask? a. "Have you lost any weight lately?" b. "Do you crave fluids containing sugar?" c. "How long have you felt anorexic?" d. "Is your urine unusually dark-colored?"

A Rationale: Weight loss occurs because the body is no longer able to absorb glucose and starts to break down protein and fat for energy. The patient is thirsty but does not necessarily crave sugar- containing fluids. Increased appetite is a classic symptom of type 1 diabetes. With the classic symptom of polyuria, urine will be very dilute. Cognitive Level: Application Text Reference: pp. 1255, 1258 Nursing Process: Assessment NCLEX: Physiological Integrity

10. The nurse excitedly tells the patient about the myoelectrically controlled prosthesis, the movement of which is controlled by: 1. the patient's muscle movement and the prosthesis. 2. battery-operated muscles implanted in the prosthesis. 3. motion-sensing mechanism that swings the prosthesis forward. 4. internal computer chip in the prosthesis.

ANS: 1 A patient's muscle movement and the prosthesis control movement with a myoelectrically controlled prosthesis.

19. Risk for injury related to unsteady gait is an appropriate nursing diagnosis for the above-knee amputee who is going home. The statement by the patient that indicates understanding of the risk is: 1. "I will have my daughter get rid of my scatter rugs." 2. "I like to keep my newspapers on the floor in front of my chair." 3. "I don't need to practice using stairs because I will only go up and down a couple of times each day." 4. "Why would I need arm exercises? They operated on my leg."

ANS: 1 Planning safety provisions indicates that the patient is aware of potential sources of injury.

5. The nurse explains that the routine preoperative diagnostic tests for a patient anticipating a below-knee amputation are: 1. pulse volume recording and WBC (white blood count). 2. cardiac catheterization and WBC. 3. pulse volume recording and x-rays. 4. thermography and cardiac catheterization.

ANS: 1 Pulse volume recording and WBC are two diagnostic tests for patients anticipating a below-knee amputation.

9. A closed amputation is usually performed to: 1. create a weight-bearing residual limb. 2. alleviate the effects of the trauma. 3. allow infection to heal and drain. 4. treat a limb with gangrene.

ANS: 1 This is the definition of a closed amputation as given in the text.

15. Preoperative exercises for a patient undergoing a lower extremity amputation include: 1. upper body training. 2. lower body training. 3. upper thigh training. 4. head and neck training.

ANS: 1 Upper body training will strengthen the arms to aid in movement after the loss of a lower extremity.

2. The nurse discriminates between an open and closed amputation by saying that a closed amputation is designed to (select all that apply): 1. prepare a weight-bearing limb. 2. cover the stump with tissue and muscle. 3. place sutures immediately over the bone. 4. be staged to closure. 5. be immediately ready for a prosthesis.

ANS: 1, 2 Closed amputations are meant to prepare the limb for weight-bearing with tissue and muscle applied to the residual limb. Sutures are not placed over the bone for future comfort and better healing. Closed amputations are not staged as are open amputations, and may or may not be prepared for an immediate prosthesis.

MULTIPLE RESPONSE 1. The nurse points out the major situational occurrences that lead to amputations are (select all that apply): 1. trauma. 2. disease. 3. tumors. 4. congenital defects. 5. carelessness.

ANS: 1, 2, 3, 4 Carelessness usually leads to trauma.

3. The nurse, when selecting possible nursing diagnoses for the 32-year-old patient who is in anticipatory grieving for an upcoming bilateral above-knee amputation, would consider (select all that apply): 1. anxiety related to knowledge deficit of procedure. 2. disturbed body image related to loss of body part. 3. sexual dysfunction related to perceived disfigurement. 4. disturbed self-image related to loss of independence. 5. activity intolerance related to pain.

ANS: 1, 2, 3, 4, 5 All concerns mentioned would need to be addressed.

23. Late signs of hemorrhage in the postoperative period following an amputation include: 1. restlessness and increasing respirations. 2. cyanosis and hypotension. 3. confusion and seizures. 4. headache and hypertension.

ANS: 2 Cyanosis and hypotension are late signs of hemorrhage in the postoperative period following an amputation.

16. The greatest danger in the early postoperative period after an amputation is: 1. infection. 2. hemorrhage. 3. pain. 4. edema.

ANS: 2 Hemorrhage is the greatest danger in the early postoperative period after an amputation.

14. An appropriate goal for a nursing diagnosis of "Anxiety related to perceived threat of disability" would be: 1. the patient will state that pain is relieved. 2. the patient will verbalize concerns about injury. 3. the patient will demonstrate realistic goal setting. 4. the patient will report that the limb did not become infected.

ANS: 2 Only option 2 is specific to the diagnosis. Others are possible goals but do not pertain to this diagnosis.

21. The nurse includes in postoperative care for a patient with reimplantation of the right thumb the implementations of: 1. decreasing the temperature of the room to 70ºF. 2. elevating the hand, but keeping it below the level of the heart. 3. offering coffee, tea, or cola to help increase fluid intake. 4. placing an antiembolus sleeve on the right arm.

ANS: 2 Slight elevation of the hand will encourage drainage, but not embarrass arterial perfusion. The room temperature should be 80º F. The patient should avoid all caffeine drinks and tight clothing or dressings.

4. The 80-year-old man with diabetes has had vascular problems with his feet and lower legs for 10 years and is scheduled for a left below-knee amputation. The remark by the patient that indicates an understanding of the procedure is: 1. "I am glad this amputation will end my diabetic problems." 2. "After they have hacked my leg, I won't be able to drive." 3. "If this heals well, how long until I get a prosthesis?" 4. "I hate that my left knee is going to be useless without a foot."

ANS: 3 Only this answer indicates that the patient realizes the extent of the surgery.

24. Patient verbalization of microvascular precautions is a criterion for measuring the achievement of which nursing goal? 1. Adequate circulation in the replanted limb 2. Pain relief 3. Patient knowledge of therapeutic measures 4. Adjustment to change in appearance and function

ANS: 3 Option 3 is the best answer, because it addresses patient knowledge. The others do not.

12. During the admission of a patient scheduled for amputation, the patient relates that she is a practicing Orthodox Jew. The nurse should make arrangements for: 1. a veil to cover the amputated part. 2. a rabbi present for the surgery. 3. the amputated part to be buried. 4. a family member present to read the Torah.

ANS: 3 Orthodox Jews bury all body parts.

3. The nurse conducting the safety seminar reminds the audience that upper extremity amputation is most frequently caused by trauma and that the highest incidence of this is: 1. school-age girls. 2. school-age boys. 3. young men. 4. young women.

ANS: 3 Young men are at greater risk from work trauma, because traditionally they are the ones working with farm and heavy machinery.

25. Which of the following postoperative observations must be reported to the physician immediately? 1. Brownish red drainage on the dressing, which is damp 2. Respirations of 20/min 3. Pulse of 72 4. Bright red bleeding

ANS: 4 Bright red bleeding is not expected and indicates hemorrhage.

6. The nurse explains that for an elbow disarticulation, the limb will be severed: 1. just above the elbow joint. 2. just below the elbow joint. 3. between the shoulder and elbow. 4. through the elbow joint.

ANS: 4 Disarticulations sever limbs through the joints.

20. The child comes to the school nurse with his index finger partially amputated and hanging by a shred of skin. The nurse should: 1. flush the hand with warm water and wrap in a towel. 2. carefully cut the skin holding the finger and wrap the finger and hand in clean towel. 3. pinch the finger to stop bleeding and take the child to the hospital 4. wrap the hand securely and place on an ice water-filled baggie.

ANS: 4 Leave the shred of skin intact, wrap the hand and finger in a normal saline-soaked towel, and place on a cool surface.

2. When the patient asks when he should expect to be up and walking after his below-knee amputation, the nurse assures him that most amputees are fully weight-bearing within: 1. 3 weeks. 2. 1 month. 3. 6 weeks. 4. 3 months.

ANS: 4 Most amputees are fully weight-bearing within 3 months after surgery.

18. A patient who amputated his thumb in a lawnmower accident hands the ER nurse his thumb in a glass jar. The nurse should: 1. place the thumb in a baggie with iced Ringer's lactate. 2. wrap the thumb in plastic wrap and place on ice. 3. leave the thumb in the jar and put it in the refrigerator. 4. wrap the thumb in a cloth saturated with normal saline and place in a baggie.

ANS: 4 The amputated part should be wrapped in a normal saline solution-soaked towel, placed in a baggie, and put in a cool bath.

7. The nurse is aware that a thermography finding of cool spots in a certain area indicates: 1. increased blood flow. 2. decreased infection. 3. increased infection. 4. decreased blood flow.

ANS: 4 The area is cool because there is less blood flow.

13. To reduce the possibility of hip contractures in an above-knee amputee, the nurse periodically places the patient in a ____ position. 1. high Fowler's 2. side-lying 3. flat supine 4. completely prone

ANS: 4 The prone position will cause the muscles of the thigh to stretch and prevent contracture.

COMPLETION 1. The nurse clarifies that the precise term for the patient's amputation, which will be through the knee joint, is called ____________________.

ANS: Disarticulation

31. A newly diagnosed type 1 diabetic patient likes to run 3 miles several mornings a week. Which teaching will the nurse implement about exercise for this patient? a. "You should not take the morning NPH insulin before you run." b. "Plan to eat breakfast about an hour before your run." c. "Afternoon running is less likely to cause hypoglycemia." d. "You may want to run a little farther if your glucose is very high."

B Rationale: Blood sugar increases after meals, so this will be the best time to exercise. NPH insulin will not peak until mid-afternoon and is safe to take before a morning run. Running can be done in either the morning or afternoon. If the glucose is very elevated, the patient should postpone the run. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity

10. A 1200-calorie diet and exercise are prescribed for a patient with newly diagnosed type 2 diabetes. The patient tells the nurse, "I hate to exercise! Can't I just follow the diet to keep my glucose under control?" The nurse teaches the patient that the major purpose of exercise for diabetics is to a. increase energy and sense of well-being, which will help with body image. b. facilitate weight loss, which will decrease peripheral insulin resistance. c. improve cardiovascular endurance, which is important for diabetics. d. set a successful pattern, which will help in making other needed changes.

B Rationale: Exercise is essential to decrease insulin resistance and improve blood glucose control. Increased energy, improved cardiovascular endurance, and setting a pattern of success are secondary benefits of exercise, but they are not the major reason. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Physiological Integrity

23. A diabetic patient is admitted with ketoacidosis and the health care provider writes all of the following orders. Which order should the nurse implement first? a. Start an infusion of regular insulin at 50 U/hr. b. Give sodium bicarbonate 50 mEq IV push. c. Infuse 1 liter of normal saline per hour. d. Administer regular IV insulin 30 U.

C Rationale: The most urgent patient problem is the hypovolemia associated with DKA, and the priority is to infuse IV fluids. The other actions can be accomplished after the infusion of normal saline is initiated. Cognitive Level: Application Text Reference: p. 1280 Nursing Process: Implementation NCLEX: Physiological Integrity

12. A patient with type 1 diabetes has an unusually high morning glucose measurement, and the health care provider wants the patient evaluated for possible Somogyi effect. The nurse will plan to a. administer an increased dose of NPH insulin in the evening. b. obtain the patient's blood glucose at 3:00 in the morning. c. withhold the nighttime snack and check the glucose at 6:00 AM. d. check the patient for symptoms of hypoglycemia at 2:00 to 4:00 AM.

B Rationale: In the Somogyi effect, the patient's blood glucose drops in the early morning hours (in response to excess insulin administration), which causes the release of hormones that result in a rebound hyperglycemia. It is important to check the blood glucose in the early morning hours to detect the initial hypoglycemia. An increased evening NPH dose or holding the nighttime snack will further increase the risk for early morning hypoglycemia. Information about symptoms of hypoglycemia will not be as accurate as checking the patient's blood glucose in determining whether the patient has the Somogyi effect. Cognitive Level: Application Text Reference: pp. 1263-1264 Nursing Process: Planning NCLEX: Physiological Integrity

1. A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what "type 2" means in relation to diabetes. The nurse explains to the patient that type 2 diabetes differs from type 1 diabetes primarily in that with type 2 diabetes a. the patient is totally dependent on an outside source of insulin. b. there is decreased insulin secretion and cellular resistance to insulin that is produced. c. the immune system destroys the pancreatic insulin-producing cells. d. the insulin precursor that is secreted by the pancreas is not activated by the liver.

B Rationale: In type 2 diabetes, the pancreas produces insulin, but the insulin is insufficient for the body's needs or the cells do not respond to the insulin appropriately. The other information describes the physiology of type 1 diabetes. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Implementation NCLEX: Physiological Integrity

25. A patient with type 1 diabetes who uses glargine (Lantus) and lispro (Humalog) insulin develops a sore throat, cough, and fever. When the patient calls the clinic to report the symptoms and a blood glucose level of 210 mg/dl, the nurse advises the patient to a. use only the lispro insulin until the symptoms of infection are resolved. b. monitor blood glucose every 4 hours and notify the clinic if it continues to rise. c. decrease intake of carbohydrates until glycosylated hemoglobin is less than 7%. d. limit intake to non-calorie-containing liquids until the glucose is within the usual range.

B Rationale: Infection and other stressors increase blood glucose levels and the patient will need to test blood glucose frequently, treat elevations appropriately with insulin, and call the health care provider if glucose levels continue to be elevated. Discontinuing the glargine will contribute to hyperglycemia and may lead to DKA. Decreasing carbohydrate or caloric intake is not appropriate as the patient will need more calories when ill. Glycosylated hemoglobins are not used to test for short-term alterations in blood glucose. Cognitive Level: Application Text Reference: p. 1272 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

3. During a diabetes screening program, a patient tells the nurse, "My mother died of complications of type 2 diabetes. Can I inherit diabetes?" The nurse explains that a. as long as the patient maintains normal weight and exercises, type 2 diabetes can be prevented. b. the patient is at a higher than normal risk for type 2 diabetes and should have periodic blood glucose level testing. c. there is a greater risk for children developing type 2 diabetes when the father has type 2 diabetes. d. although there is a tendency for children of people with type 2 diabetes to develop diabetes, the risk is higher for those with type 1 diabetes.

B Rationale: Offspring of people with type 2 diabetes are at higher risk for developing type 2 diabetes. The risk can be decreased, but not prevented, by maintenance of normal weight and exercising. The risk for children of a person with type 1 diabetes to develop diabetes is higher when it is the father who has the disease. Offspring of people with type 2 diabetes are more likely to develop diabetes than offspring of those with type 1 diabetes. Cognitive Level: Application Text Reference: p. 1256 Nursing Process: Implementation NCLEX: Physiological Integrity

34. The health care provider orders oral glucose tolerance testing for a patient seen in the clinic. Which information from the patient's health history is most important for the nurse to communicate to the health care provider? a. The patient had a viral illness 2 months ago. b. The patient uses oral contraceptives. c. The patient runs several days a week. d. The patient has a family history of diabetes.

B Rationale: Oral contraceptive use may falsely elevate oral glucose tolerance test (OGTT) values. A viral 2 months previously illness may be associated with the onset of type 1 diabetes but will not falsely impact the OGTT. Exercise and a family history of diabetes both can affect blood glucose but will not lead to misleading information from the OGTT. Cognitive Level: Application Text Reference: p. 1267 Nursing Process: Assessment NCLEX: Physiological Integrity

15. A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient about mealtime coverage using _____ insulin. a. NPH b. lispro c. detemir d. glargine

B Rationale: Rapid or short acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin. Cognitive Level: Application Text Reference: p. 1260 Nursing Process: Planning NCLEX: Physiological Integrity

13. A patient receives a daily injection of 70/30 NPH/regular insulin premix at 7:00 AM. The nurse expects that a hypoglycemic reaction is most likely to occur between a. 8:00 and 10:00 AM. b. 4:00 and 6:00 PM. c. 7:00 and 9:00 PM. d. 10:00 PM and 12:00 AM.

B Rationale: The greatest insulin effect with this combination occurs mid afternoon. The patient is not at a high risk at the other listed times, although hypoglycemia may occur. Cognitive Level: Comprehension Text Reference: p. 1260 Nursing Process: Evaluation NCLEX: Physiological Integrity

35. Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient? a. Fasting blood glucose of 130 mg/dl b. Noon blood glucose of 52 mg/dl c. Glycosylated hemoglobin of 6.9% d. Hemoglobin A1C of 5.8%

B Rationale: The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient. Cognitive Level: Application Text Reference: pp. 1281-1282 Nursing Process: Assessment NCLEX: Physiological Integrity

30. A patient with type 2 diabetes has sensory neuropathy of the feet and legs and peripheral vascular disease evidenced by decreased peripheral pulses and dependent rubor. The nurse teaches the patient that a. the feet should be soaked in warm water on a daily basis. b. flat-soled leather shoes are the best choice to protect the feet from injury. c. heating pads should always be set at a very low temperature. d. over-the-counter (OTC) callus remover may be used to remove callus and prevent pressure.

B Rationale: The patient is taught to avoid high heels and that leather shoes are preferred. The feet should be washed, but not soaked, in warm water daily. Heating pad use should be avoided. Commercial callus and corn removers should be avoided; the patient should see a specialist to treat these problems. Cognitive Level: Application Text Reference: p. 1287 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

33. A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. Which information obtained by the nurse when admitting the patient indicates a need for a change in the patient's regimen? a. The patient's most recent hemoglobin A1C was 6%. b. The patient takes metformin (Glucophage) every morning. c. The patient uses captopril (Capoten) for hypertension. d. The patient's admission blood glucose is 128 mg/dl.

B Rationale: To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast media are administered. The other patient data indicate that the patient is managing the diabetes appropriately. Cognitive Level: Application Text Reference: p. 1266 Nursing Process: Assessment NCLEX: Physiological Integrity

38. A diabetic patient has a new order for inhaled insulin (Exubera). Which information about the patient indicates that the nurse should contact the patient before administering the Exubera? a. The patient has a history of a recent myocardial infarction. b. The patient's blood glucose is 224 mg/dl. c. The patient uses a bronchodilator to treat emphysema. d. The patient's temperature is 101.4° F.

C Rationale: Exubera is not recommended for patients with emphysema. The other data do not indicate any contraindication to using Exubera. Cognitive Level: Application Text Reference: p. 1263 Nursing Process: Assessment NCLEX: Physiological Integrity

24. A diagnosis of hyperglycemic hyperosmolar nonketotic coma (HHNC) is made for a patient with type 2 diabetes who is brought to the emergency department in an unresponsive state. The nurse will anticipate the need to a. administer glargine (Lantus) insulin. b. initiate oxygen by nasal cannula. c. insert a large-bore IV catheter. d. give 50% dextrose as a bolus.

C Rationale: HHNC is initially treated with large volumes of IV fluids to correct hypovolemia. Regular insulin is administered, not a long-acting insulin. There is no indication that the patient requires oxygen. Dextrose solutions will increase the patient's blood glucose and would be contraindicated. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Planning NCLEX: Physiological Integrity

29. A type 1 diabetic patient who was admitted with severe hypoglycemia and treated tells the nurse, "I did not have any of the usual symptoms of hypoglycemia." Which question by the nurse will help identify a possible reason for the patient's hypoglycemic unawareness? a. "Do you use any calcium-channel blocking drugs for blood pressure?" b. "Have you observed any recent skin changes?" c. "Do you notice any bloating feeling after eating?" d. "Have you noticed any painful new ulcerations or sores on your feet?"

C Rationale: Hypoglycemic unawareness is caused by autonomic neuropathy, which would also cause delayed gastric emptying. Calcium-channel blockers are not associated with hypoglycemic unawareness, although -adrenergic blockers can prevent patients from having symptoms of hypoglycemia. Skin changes can occur with diabetes, but these are not associated with autonomic neuropathy. If the patient can feel painful areas on the feet, neuropathy has not occurred. Cognitive Level: Application Text Reference: p. 1281 Nursing Process: Assessment NCLEX: Physiological Integrity

7. A patient who has just been diagnosed with type 2 diabetes is 5 ft 4 in (160 cm) tall and weighs 182 pounds (82 kg). A nursing diagnosis of imbalanced nutrition: more than body requirements is developed. Which patient outcome is most important for this patient? a. The patient will have a diet and exercise plan that results in weight loss. b. The patient will state the reasons for eliminating simple sugars in the diet. c. The patient will have a glycosylated hemoglobin level of less than 7%. d. The patient will choose a diet that distributes calories throughout the day.

C Rationale: The complications of diabetes are related to elevated blood glucose, and the most important patient outcome is the reduction of glucose to near-normal levels. The other outcomes are also appropriate but are not as high in priority. Cognitive Level: Application Text Reference: p. 1273 Nursing Process: Planning NCLEX: Physiological Integrity

6. During a clinic visit 3 months following a diagnosis of type 2 diabetes, the patient reports following a reduced-calorie diet. The patient has not lost any weight and did not bring the glucose-monitoring record. The nurse will plan to obtain a(n) a. fasting blood glucose level. b. urine dipstick for glucose. c. glycosylated hemoglobin level. d. oral glucose tolerance test.

C Rationale: The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed. Cognitive Level: Application Text Reference: pp. 1258-1259 Nursing Process: Planning NCLEX: Physiological Integrity

19. A hospitalized diabetic patient receives 12 U of regular insulin mixed with 34 U of NPH insulin at 7:00 AM. The patient is away from the nursing unit for diagnostic testing at noon, when lunch trays are distributed. The most appropriate action by the nurse is to a. save the lunch tray to be provided upon the patient's return to the unit. b. call the diagnostic testing area and ask that a 5% dextrose IV be started. c. ensure that the patient drinks a glass of milk or orange juice at noon in the diagnostic testing area. d. request that the patient be returned to the unit to eat lunch if testing will not be completed promptly.

D Rationale: Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items. Cognitive Level: Analysis Text Reference: p. 1268 Nursing Process: Implementation NCLEX: Physiological Integrity

27. A patient recovering from DKA asks the nurse how acidosis occurs. The best response by the nurse is that a. insufficient insulin leads to cellular starvation, and as cells rupture they release organic acids into the blood. b. when an insulin deficit causes hyperglycemia, then proteins are deaminated by the liver, causing acidic by-products. c. excess glucose in the blood is metabolized by the liver into acetone, which is acidic. d. an insulin deficit promotes metabolism of fat stores, which produces large amounts of acidic ketones.

D Rationale: Ketoacidosis is caused by the breakdown of fat stores when glucose is not available for intracellular metabolism. The other responses are inaccurate. Cognitive Level: Application Text Reference: pp. 1278-1279 Nursing Process: Implementation NCLEX: Physiological Integrity

9. A patient with type 1 diabetes has received diet instruction as part of the treatment plan. The nurse determines a need for additional instruction when the patient says, a. "I may 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 will eat meals as scheduled, even if I am not hungry, to prevent hypoglycemia." d. "I may eat whatever I want, as long as I use enough insulin to cover the calories."

D Rationale: Most patients with type 1 diabetes need to plan diet choices very carefully. Patients who are using intensified insulin therapy have considerable flexibility in diet choices but still should restrict dietary intake of items such as fat, protein, and alcohol. The other patient statements are correct and indicate good understanding of the diet instruction. Cognitive Level: Application Text Reference: p. 1268 Nursing Process: Evaluation NCLEX: Physiological Integrity

37. The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the a. thigh. b. buttock. c. arm. d. abdomen.

D Rationale: Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle. Cognitive Level: Application Text Reference: p. 1262 Nursing Process: Implementation NCLEX: Physiological Integrity

8. A college student who has type 1 diabetes normally walks each evening as part of an exercise regimen. The student now plans to take a swimming class every day at 1:00 PM. The clinic nurse teaches the patient to a. delay eating the noon meal until after the swimming class. b. increase the morning dose of neutral protamine Hagedorn (NPH) insulin on days of the swimming class. c. time the morning insulin injection so that the peak occurs while swimming. d. check glucose level before, during, and after swimming.

D Rationale: The change in exercise will affect blood glucose, and the patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. Increasing the morning NPH or timing the insulin to peak during exercise may lead to hypoglycemia, especially with the increased exercise. Cognitive Level: Application Text Reference: p. 1269 Nursing Process: Implementation NCLEX: Health Promotion and Maintenance

4. A program of weight loss and exercise is recommended for a patient with impaired fasting glucose (IFG). When teaching the patient about the reason for these lifestyle changes, the nurse will tell the patient that a. the high insulin levels associated with this syndrome damage the lining of blood vessels, leading to vascular disease. b. although the fasting plasma glucose levels do not currently indicate diabetes, the glycosylated hemoglobin will be elevated. c. the liver is producing excessive glucose, which will eventually exhaust the ability of the pancreas to produce insulin, and exercise will normalize glucose production. d. the onset of diabetes and the associated cardiovascular risks can be delayed or prevented by weight loss and exercise.

D Rationale: The patient with IFG is at risk for developing type 2 diabetes, but this risk can be decreased with lifestyle changes. Glycosylated hemoglobin levels will not be elevated in IFG and the Hb A1C test is not included in prediabetes testing. Elevated insulin levels do not cause the damage to blood vessels that can occur with IFG. The liver does not produce increased levels of glucose in IFG. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Implementation NCLEX: Physiological Integrity

2. A 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. use of low doses of regular insulin. b. self-monitoring of blood glucose. c. oral hypoglycemic medications. d. maintenance of a healthy weight.

D Rationale: The patient's impaired fasting glucose indicates prediabetes and the patient should be counseled about lifestyle changes to prevent the development of type 2 diabetes. The patient with prediabetes does not require insulin or the oral hypoglycemics for glucose control and does not need to self-monitor blood glucose. Cognitive Level: Application Text Reference: p. 1255 Nursing Process: Planning NCLEX: Physiological Integrity