synthesis part 2

• A child is having a generalized tonic-clonic seizure. Which action should the nurse take? o Move objects out of the child's immediate area o Quickly slip soft restraints on the child's wrists o Insert a padded tongue blade between the teeth o Place in the recovery position before going for help

A

• A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; Pco2 48; Po2 58; HCO3 26. Which of the following orders should the nurse perform first? o Albuterol (Proventil) nebulizer. o Chest x-ray. o Ipratropium (Atrovent) inhaler. o Sputum culture.

A

• A client who is started on metformin and glyburide would have initially presented with which symptoms? o Polydispisa, polyuria, and weight loss o weight gain, tiredness, & bradycardia o irritability, diaphoresis, and tachycardia o diarrhea, abdominal pain, and weight loss

A

• A client with a T2 to T3 spinal cord injury (SCI) suddenly has a throbbing headache and blurred vision. The client is flushed and sweating on the upper trunk and face, and the hairs on the arms are raised. What should the nurse do first? o Raise the head of the bed. o Assess for hypotension. o Check the client for a distended bladder. o Logroll the client to see if the client is lying on a foreign object

A

• A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which of the following findings would the nurse expect to note as confirming this diagnosis? o Elevated blood glucose and low plasma bicarbonate o Decreased urine output o Increased respirations and an increase in pH o Coma

A

• A female client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? o "You may have difficulty believing this, but the paralysis caused by this disease is temporary." o "You'll have to accept the fact that you're permanently paralyzed. However, you won't have any sensory loss." o "It must be hard to accept the permanency of your paralysis." o "You'll first regain use of your legs and then your arms."

A

• If a patient is suspected to have an acute onset of SIADH which would be the most important assessment finding for the nurse to report to the doctor immediately? o A weight gain of 3lbs overnight o A weight loss of 3lbs overnight o A normal set of vital signs o A urine specific gravity of 1.010

A

• On the ICU, a client with head trauma is on continuous mechanical ventilation and develops increased ICP. Which intervention should the nurse implement first? o Call the provider anticipating orders to hyperventilate the client. o Increase the oxygen concentration. o Position in Trendelenburg. o Suction the ETT.

A

• The nurse is assessing a client who has a closed head injury. The client presents with confusion, drowsiness, and unequal pupils. Which of the following nursing diagnoses takes priority? o Altered cerebral perfusion o Altered level of cognitive function o High risk for injury o Sensory perceptual alteration

A

• The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment? o Hyperthermia related to infectious illness o Ineffective thermoregulation related to chilling o Ineffective breathing pattern related to pneumonia o Ineffective airway clearance related to thick secretions

A

• The nurse is obtaining a health history for a client admitted to the hospital with a tentative diagnosis of Guillain- Barre syndrome. Which health history question will best elicit information that supports the diagnosis? o "Have you experienced an infection lately?" o "Is there a history of this disorder in your family?" o "Did you receive a head injury in the past year?" o "What medications have you taken in the last 3 months?"

A

• The nurse is reviewing recent laboratory values for an adult male client who is being treated for malnutrition. Which laboratory finding indicates that the client is not receiving adequate iron supplementation? o Hematocrit, 31% o Serum albumin, 3.5 g/dL o Creatine phosphokinase (CPK), 55 U/mL o Erythrocyte sedimentation rate (ESR), 15.8 mm/hr

A

• The nurse is working on a surgical floor. The nurse must logroll a male client following a: o laminectomy. o thoracotomy. o hemorrhoidectomy. o cystectomy.

A

• What are the early signs of cerebral hypoxia? o Irritability and restlessness o Nausea and unconsciousness o Eyes rolling back and fingernail clubbing o Headache and tachycardia

A

• When caring for a client with diabetes insipidus, the nurse expects to administer: o vasopressin (Pitressin Synthetic) o furosemide (Lasix). o regular insulin. o 10% dextrose.

A

• Which outcome indicates that treatment of a male client with diabetes insipidus has been effective? o Fluid intake is less than 2,500 ml/day. o Urine output measures more than 200 ml/hour. o Blood pressure is 90/50 mm Hg. o The heart rate is 126 beats/minute.

A

• A client with tuberculosis is taking isoniazid. To help prevent the development of peripheral neuropathies, the nurse should instruct the client to: o Adhere to a low-cholesterol diet o Supplement the diet with pyridoxine (vitamin B) o Get extra rest o Avoid excessive sun exposure

B

• A nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops? o Polyuria o Shakiness o Blurred vision o Fruity breath odor

B

• The healthcare provider is conducting teaching during a health fair about the causes of pneumonia. The healthcare provider demonstrates understanding of the causes when she states that community acquired pneumonia (CAP) can be caused by all of the following except: o Mycoplasma o Human papillomavirus o Influenza o Streptococcus pneumonia

B

• The nurse is caring for a client who is medicated with daily Metformin and will undergo a computed tomography (CT scan) with IV contrast dye to provide information about the kidneys, ureters, and bladder. The nurse understands that patients who receive Metformin require which of the following actions prior to the computed tomography (CT scan) with IV contrast dye: o Continue to administer Metformin prior to the CT scan with IV contrast dye o Discontinue the Metformin at least 24 hours before the time of the CT scan with contrast dye and for at least 48 hours after the CT scan o Administer the Metformin dose at half the normal dose o Administer the Metformin dose 3 hours after the CT scan with IV contrast dye

B

• The nurse is caring for a patient admitted with a subdural hematoma following a motor vehicle accident. Which of the following changes in vital signs would the nurse interpret as a manifestation of increased intracranial pressure? o Tachypnea o Bradycardia o Hypotension o Narrowing pulse pressure

B

• Which of the following nursing interventions is of the highest priority in helping a patient expectorate thick secretions related to pneumonia? o Humidify the oxygen as able o Increase fluid intake to 3L/day if tolerated. o Administer cough suppressant q4hr. o Teach patient to splint the affected area.

B

• Which patient below is at MOST risk for increased intracranial pressure? o A patient who is experiencing severe hypotension. o A patient who is admitted with a traumatic brain injury. o A patient who recently experienced a myocardial infarction. o A patient post-op from eye surgery.

B

• With acute pulmonary emboli, what do you expect to see on ABGs? o Hypoxemia, hypercapnia, academia o Hypoxemia, hypocapnia, alkalemia o Hyperoxemia, hypocapnia, alkalemia o Hyperoxemia, hypocapnia, alkalemia

B

• A nurse is assessing a client for hemorrhage after the client underwent a transsphenoidal hypophysectomy. Which of the following signs may be present? o Bloody stool o Bracycardia o Frequent swallowing o Petechiae of the face

C

• A nurse is assisting a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) to develop a plan to prevent a recurrence. Which is most important to include in the plan of care? o Test urine for ketone levels. o Eat six small meals per day. o Monitor blood glucose levels frequently. o Receive appropriate follow-up health care

C

• A nurse is caring for a client who displays signs of stage III Parkinson's disease. Which of the following actions should the nurse include in the plan of care? o Recommend a community support group. o Integrate a daily exercise routine. o Provide a walker for ambulation o Perform ADLs for the client

C

• During assessment of a patient with dementia, the nurse determines that the condition is potentially reversible when finding out what about the patient? o Has long-standing abuse of alcohol o Has a history of Parkinson's disease o Recently developed symptoms of hypothyroidism o Was infected with human immunodeficiency virus (HIV) 10 years ago

C

• For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: o prevent respiratory alkalosis. o lower arterial pH. o promote carbon dioxide elimination. o maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

C

• The nurse is assessing the client diagnosed with bacterial meningitis. Which clinical manifestation would support the diagnosis of bacterial meningitis? o Positive Babinski's sign and peripheral paresthesia o Negative Chvostek's sign and facial tingling o Positive Kernig's sign and nuchal rigidity o Negative Trousseau's sign and nystagmus

C

• The nurse is caring for a client with cancer of the prostate who has undergone a prostatectomy. Which action should the nurse tell the client to take when providing discharge instructions? o Avoid driving the car for a few days o Restrict fluid intake to prevent incontinence o Avoid lifting objects heavier than 20 lb for at least 6 weeks o Notify the health care provider if small blood clots are noticed during urination

C

• The nurse is instructing the client with Vitamin B-12 deficiency to eat which foods to obtain the best supply of vitamin B-12? o Whole grains. o Green leafy vegetables. o Meat and dairy products. o Broccoli and Brussel sprouts.

C

• The nurse suspects that the client is altering her diabetic journals to please her HCP. Which lab test should the RN review to assess the client's compliance with self management for DM type 1? o oral glucose tolerance test (OGTT) o 24-hour urine analysis o hemoglobin A1C o Fasting cholesterol

C

• Which nursing action would be appropriate to implement when a client has a diagnosis of pheochromocytoma? o Weigh the client. o Test the client's urine for glucose. o Monitor the client's blood pressure. o Palpate the client's skin to determine warmth.

C

• Which of the following patients is MOST LIKELY experiencing Hyperglycemic Hyperosmolar Nonketotic Syndrome based on their symptoms? o A 72 year old with a health history of diabetes who has a blood glucose of 300 mg/dL and is complaining of thirst and frequent urination. o A 66 year old with type I diabetes that has ketones present in their urine. o A 69 year old admitted with an infection of the right foot with a health history of diabetes that reports missing several doses of Metformin and has a blood glucose of 600 mg/dL. o A 6 year old that is presenting with polyuria, polydipsia, abdominal pain, and vomiting.

C

• Which of the following statements is INCORRECT about Hyperglycemic Hyperosmolar Nonketotic Syndrome? o HHNS occurs mainly in type 2 diabetics. o This condition presents without ketones in the urine. o Metabolic alkalosis presents in severe HHNS. o Intravenous Regular insulin is used to treat hyperglycemia.

C

• A client with severe head trauma sustained in a car accident is admitted to the intensive care unit. Thirty-six hours later, the client's urine output suddenly rises above 200 ml/hour, leading the nurse to suspect diabetes insipidus. Which laboratory findings support the nurse's suspicion of diabetes insipidus?vasopressin (Pitressin Synthetic) o Above-normal urine and serum osmolality levels o Below-normal urine and serum osmolality levels o Above-normal urine osmolality level, below-normal serum osmolality level o Below-normal urine osmolality level, above-normal serum osmolality level

D

• A female client has clear fluid leaking from the nose following a basilar skull fracture. The nurse assesses that this is cerebrospinal fluid if the fluid: o Is clear and tests negative for glucose o Is grossly bloody in appearance and has a pH of 6 o Clumps together on the dressing and has a pH of 7 o Separates into concentric rings and test positive of glucose

D

• A female client is admitted in a disoriented and restless state after sustaining a concussion during a car accident. Which nursing diagnosis takes highest priority in this client's plan of care? o Disturbed sensory perception (visual) o Self-care deficient: Dressing/grooming o Impaired verbal communication o Risk for injury

D

• A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed, and the pulse and respiratory rate are elevated from the client's baseline. The nurse would immediately: o Prepare for the administration of an insulin drip. o Give the client a glass of orange juice. o Prepare for the administration of a bolus dose of 50% dextrose. o Check the client's capillary blood glucose.

D

• A patient comes to the emergency department immediately after experiencing numbness of the face and an inability to speak, but while the patient awaits examination, the symptoms disappear and the patient request discharge. The nurse stresses that it is important for the patient to be evaluated primarily because o the patient has probably experienced an asymptomatic lacunar stroke o the symptoms are likely to return and progress to worsening neurologic deficit in the next 24 hours o neurologic deficits that are transient occur most often as a result of small hemorrhages that clot off o the patient has probably experienced a transient ischemic attack (TIA), which is a sign of progressive cerebral vascular disease

D

• After a patient with right lower-lobe pneumonia has been treated with intravenous (IV) antibiotics for 2 days, which assessment data obtained by the nurse indicates that the treatment has been effective? o The patient coughs up small amounts of green mucus. o Increased tactile fremitus is palpable over the right chest. o Bronchial breath sounds are heard at the right base. o The patient's white blood cell (WBC) count is 9000/µl

D

• Bacterial meningitis alters intracranial physiology, causing o Cerebral edema o Increased permeability of the blood-brain barrier o Raised intracranial pressure o All of the above changes

D

• The emergency department nurse is reviewing the laboratory test results for a client suspected of having diabetic ketoacidosis (DKA). Which laboratory result should the nurse expect to note in this disorder? o Serum pH of 9.0 o Absent ketones in the urine o Serum bicarbonate of 22 mEq/L o Blood glucose level of 500 mg/dL

D

• The nurse is caring for a client who has global aphasia. Which of the following communication approaches is most effective to facilitate communication with a client with global aphasia? o speaking quickly and turning away from the client o ask yes / no questions o Ask the LPN / UAP to communicate with the client o Use pictures, diagrams and gestures

D

• The nurse should include which of the following instructions when developing a teaching plan for clients receiving INH and rifampin for treatment for TB? o Take the medication with antacids o Double the dosage if a drug dose is forgotten o Increase intake of dairy products o Limit alcohol intake

D

• The nurse walks into the room and observes the client experiencing a tonic-clonic seizure. Which intervention should the nurse implement first? o Restrain the client to protect from injury o Flex the neck to ensure stabilization o Use a tongue blade to open the airway o Turn the client on the side to aid ventilation

D

• The spouse of a client who experienced a cerebrovascular accident does not want the client to participate in self- care. Which of these actions by the nurse is most appropriate? o Tell the spouse to allow the client do as much as possible independently. o Allow the spouse to assume total responsibility for the client's care. o Explain that the nursing staff has full responsibility for the client's activities. o Ask the spouse for assistance in planning those activities most helpful to the client.

D

• When caring for a patient with syndrome of SIADH, the nurse anticipates which electrolyte which electrolyte abnormality characteristic of this disease? o Hyperkalemia o Hypocalcemia o Hypokalemia o Hyponatremia

D

• Which strategy is most important for the nurse to include in the plan of care for use when teaching a cognitively impaired teen about self-care for diabetes? o Encourage the teen to post questions on social media sites specialized for children with chronic illness. o Ask the teen what works best for learning complicated material. o Reinforce previously taught information only when the parent is present along with the teen. o Check the teen's understanding of the information frequently during each teaching session.

D

• What should the nurse do to prevent catheter-associated urinary tract infection (CAUTI)? Select all that apply? o Change the catheter daily o Provide perineal care several times a day o Monitor the temperature as an indicator of the infection o Encourage the client to drink 3,000 mL fluids daily o Recommend the healthcare provider prescribe antibiotics

b, c, d

• A patient has developed syndrome of inappropriate antidiuretic hormone (SIADH) after suffering a traumatic brain injury. After treatment has been initiated, the nurse assesses the patient for signs of improvement, including - Select All That Apply o decreased serum sodium o decreased urine osmolality o decreased urine output o increased serum sodium o increased urine osmolality o increased urine output

decreased urine osmolality increased serum sodium increased urine output

• A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings would the nurse expect to note as confirming this diagnosis? Select all that apply. o increase in pH o comatose state o deep, rapid breathing o decreased urine output o elevated blood glucose level o low plasma bicarbonate level

deep, rapid breathing elevated blood glucose level low plasma bicarbonate level

• A nurse is teaching a patient with Type 2 Diabetes about preventative measures to avoid long-term complications. Which of the following statements should the nurse include in the instructions? [Select all that apply] o "Wear socks with your shoes." o "Choose well fitting, supportive shoes." o "Avoid wearing boots that extend beyond your ankles." o "Avoid wearing open-toed shoes." o "Wear slippers when walking around your house."

everything but B

• A nurse is teaching a patient with Type 2 Diabetes about preventative measures to avoid long-term complications. Which of the following statements should the nurse include in the instructions? [Select all that apply] o "Wear socks with your shoes." o "Choose well fitting, supportive shoes." o "Avoid wearing boots that extend beyond your ankles." o "Avoid wearing open-toed shoes." o "Wear slippers when walking around your house."

everything but c

• Which findings should the nurse report to the HCP for a client with unstable type 1 diabetes mellitus? Select all that apply. o Systolic blood pressure, 145 mm Hg o Diastolic blood pressure, 87 mm Hg o High-density lipoprotein (HDL), 30 mg/dL o Glycosylated hemoglobin, 10.2% o Triglycerides, 425 mg/dL o Urine ketones, negative

everything but urine ketones, negative

• Which of these components of an older adult client's health history is associated with increased risk of a cerebrovascular accident (CVA)? [Select all that apply]. o Glaucoma o Hypertension o Hypothyroidism o Atrial fibrillation o Transient ischemia attacks (TIAs)

hypertension atrial fibrillation transient ischemia attacks (TIAs)

• A nurse caring for a 50 yo newly diagnosed with Parkinson's disease would want to educate the client and the family about which of the following symptoms? Select all That Apply o A mask-like expression o A shuffling gait o A wide-based gait o Difficulty swallowing o Fluctuating muscle weakness o Muscle rigidity o Optic neuritis

mask-like expression shuffling gait difficulty swallowing muscle rigidity

• A male patient with COPD becomes dyspneic at rest. His baseline blood gas results are PaO2 70 mm Hg, PaCO2 52 mm Hg, and pH 7.34. What updated patient assessment requires the nurse's priority intervention? o Arterial pH 7.26 o PaCO2 50 mm Hg o Patient in tripod position o Increased sputum expectoration

A

• A nurse is assisting in preparing a care plan for a client with diabetes mellitus who has hyperglycemia. The nurse focuses on which potential problem for this client? o Dehydration o The need for knowledge about the causes of hyperglycemia o Lack of knowledge about nutrition o Inability of family to cope with the client's diagnosis

A

• A nurse is reviewing discharge teaching with a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood? o "I can eat foods that contain potassium." o "I will need to limit the amount of protein in my diet." o "I am fortunate that I can eat all the salty foods I enjoy." o "I am fortunate that I do not need to follow any special diet."

A

• A previously healthy client is hospitalized with left lower lobe (LLL) bacterial pneumonia. The nurse assesses chest pain with inspiration, productive cough of thick rusty sputum, and LLL fine inspiratory crackles and low-pitched expiratory wheezing. Which of the medications that the health care provider prescribes should the nurse question? o Furosemide 20 mg IV push every day o Guaifenesin ER 600 mg PO every 12 hours o Ibuprofen 600 mg PO every 6 hours PRN o Levofloxacin 500 mg IV every day

A

• The nurse is teaching a group of clients diagnosied with diabetes mellitus. Which lesson regarding foot care should be included? Select all that apply o Cut toenails straight across and file along the curves of the toes o Rub feet vigorously with a towel after bathing to ensure dryness o Use a mild foot powder on perspiring feet o Use cotton or lamb's wool to separate overlapping toes o Use an over-the-counter corn removal kit to remove corns or calluses

A, C, D

• A client had a Mantoux test result of an 8-mm induration. The test is considered positive when the client: o Lives in a long-term care facility. o Has no known risk factors o Is immunocompromised o Works as a healthcare provider in a hospital

C

• A client who sustained a subarachnoid hemorrhage was placed on subarachnoid (aneurysm) precautions. Which of the following is most appropriate for this client? o Bright lights o Fleet enema o Stool softeners o Television

C

• A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which finding has the greatest effect on fluid loss? o Hypotension o Decreased serum potassium level o Rapid, deep respirations o Warm, dry skin

C

• A nurse is assessing a client to see if he is comatose. Which of the following GCS is indicative of a coma? o Nine o One o Six o Zero

C

• A 25 yo client is admitted with an injury resulting in a complete C7 transection of the spinal cord. Which action should the nurse anticipate the need for in the immediate post-op period? o Bladder and bowel training o Diaphragmatic pacing o Monitoring for autonomic dysreflexia o Ventilatory support

D

• A client with cirrhosis develops increasing pedal edema and ascites. What dietary modification is most important for the nurse to teach this client? o Avoid high carbohydrate foods. o Decrease intake of fat soluble vitamins. o Decrease caloric intake. o Restrict fluid and salt intake.

D

• The nurse is reviewing the laboratory test results for a client suspected of having diabetic ketoacidosis (DKA). Which laboratory result should the nurse expect to note in this disorder? o Serum pH of 9.0 o Absent ketones in the urine o Serum bicarbonate of 22 mEq/L o Blood glucose level of 500 mg/dL

D

• Which of the following patients are MOST at risk for developing myxedema coma? o A 28 year old female who is prescribed Methimazole. o A 75 year old female who is taking Lithium and reports missing several doses of Synthroid. o A 69 year old male experiencing nausea and vomiting for 4 days. o A 55 year old male with a history of diabetes and is insulin dependent.

b

• A client with a urinary tract infection is to take nitrofurantoin four times each day. The client asks the nurse, "What should I do if I forget a dose?" What should the nurse tell the client? o You can wait and take the next dose when it is due o Double the amount prescribed with your next dose o Take the prescribed dose as soon as you remember it, and if it is very close to the time for your next dose, delay that next dose o Take a lot of water with a double amount of your prescribed dose

c

• A client with type I diabetes is placed on an insulin pump. The most appropriate short-term goal when teaching this client to control the diabetes is: o Adhere to the medical regimen o Remain normoglycemic for 3 weeks o Demonstrate the correct use of the administration equipment. o List 3 self-care activities that are necessary to control the diabetes

c

• A patient is receiving treatment for myxedema coma with IV Synthroid. Which of the following findings would require nursing intervention for this patient? o Blood glucose 75 o Sodium level 138 o A physician's order for Fentanyl 0.25 mg q 2 hrs for pain o Temp 98.9 F

c

• The nurse is providing discharge teaching to a client with Addison's disease. Which of the following client statements is correct? Select All That Apply o "Experiencing flu-like symptoms is expected and does not require attention." o "I need to take my hydrocortisone for two weeks." o "I need to wear a Medic-alert bracelet." o "I will avoid strenuous exercise." o "I will call the physician before all dental procedures." o "I will call the physician if I feel severly weak or fatigued."

c, d, e, f

• A 10-month-old infant is carried into the emergency room by her parents. They report that she fell down 15 stairs in her walker. The nurse should take which immediate action? o Ensure a patent airway while simultaneously maintaining cervical spine precautions. o Assess airway, breathing, and circulation simultaneously. o Prepare for diagnostic radiological testing to check for any injuries. o Obtain blood and urine specimens for laboratory testing.

a

• A client with diabetes mellitus visits a health care clinic. The client's diabetes previously had been well-controlled with glyburide (Diabeta), 5 mg PO daily, but recently the fasting blood glucose has been running 180-200mg/dl. Which medication, if added to the clients regimen, may have contributed to the hyperglycemia? o Prednisone (Deltasone) o Atenolol (Tenormin) o Phenelzine (Nardil) o Allopurinol (Zyloprim)

a

• A nurse is caring for a client who is postoperative lumbar puncture and reports a throbbing headache when sitting upright. Which of the following actions should the nurse take? (Select ALL that apply) o Use the Glascow Coma Scale when assessing the client. o Assist the client to the supine position. o Encourage the client to increase fluid intake. o Instruct the client to perform deep breathing and coughing exercises. o Administer an opioid medication.

assist client to the supine position encourage the client to increase fluid intake administer an opioid medication