322 Exam 1
Which mediation can the nurse administer through a nasogastric (NG) tube?
acetaminophen Most oral medications can be given through an NG tube because they're intended for passage into the stomach. Some oral drugs have special coatings intended to keep the pill intact until it passes into the small intestine. These enteric-coated pills shouldn't be crushed and put through an NG tube. Some parenteral medications, such as insulin, may be destroyed by gastric juices. Sublingual medications must be given under the tongue.
A nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to prevent
aspiration. Checking tube placement and checking for residual volume protects the client from aspiration, which can cause pneumonia, a potentially life-threatening disorder. The nurse's actions don't prevent gastric ulcers. Although abdominal distention and diarrhea can be associated with tube feeding the nurse's actions don't prevent their occurrence, and neither condition is immediately life-threatening.
A nurse is discussing nutrition and weight control with clients during a class about diabetes. Which statement best reflects the purpose of nutritional management of diabetes?
to maintain blood glucose levels close to the normal range to reduce risk for long-term complications Maintaining normal blood glucose is the most important factor in preventing long-term complications associated with diabetes. Therefore, the most important purpose of nutritional management is maintaining blood glucose as close to normal as possible to prevent long-term complications. Following nutritional recommendations will meet energy needs, may contribute to weight control, and keep cholesterol levels within acceptable ranges, but the most important reason for nutritional management is to maintain blood sugars in the normal range.
The child's provider orders 720 ml of total parenteral nutrition (TPN) to be infused over the next 24 hours. The nurse will record TPN intake of how many milliliters at the end of the eight hour shift? Record your answer using a whole number.
240 The nurse may calculate the rate two ways. First method: 720 ml TPN ÷ 24 hours = 30 ml/hour; 30 ml/hour x 8 hours = 240 ml. Second method: 720 ml TPN ÷ 3 (i.e., three 8-hour segments in 24 hours) = 240 ml.
The nurse is preparing to initiate an enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What intervention will the nurse include in the client's plan of care?
Ensure patency of the tube. Verification of patency prior to each feeding is essential to prevent aspiration; never use any equipment that is not specifically developed for enteral feeding. Residual volumes should be examined prior to starting the feeding, not after. Placing a client prone (on the stomach) is an inappropriate intervention.
A client with diabetes is found unconscious after the morning dose of insulin. What would be a priority nursing intervention at this time?
Initiate treatment for hypoglycemia as a result of insulin. During treatment for diabetes, the client may develop hypoglycemia. Careful observation for this complication should be made by the nurse, and the nurse would begin treatment for hypoglycemia immediately to prevent it from progressing. The client would not be able to take fluids while unconscious. Withholding glucose will contribute to worsening hypoglycemia. The healthcare provider should be contacted after the client has stabilized.
The nurse is caring for a client in the medical unit. The nurse receives a health care provider's order for hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse understands that this treatment is common in clients with which disease process?
Addison's disease Intravenous hydrocortisone for clients in acute adrenal crisis is the proper treatment for individuals with Addison's disease. Cushing's syndrome is associated with excessive amounts of glucocorticoids. Hyperthyroidism and hypoparathyroidism are not treated with hydrocortisone.
A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl (2.2 mmol/L). His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?
Administering 1 ampule of 50% dextrose solution, per physician's order The nurse should administer 50% dextrose solution to restore the client's physiological integrity. Feeding through a feeding tube isn't appropriate for this client. A bolus of normal saline solution doesn't provide the client with the much-needed glucose. Observing the client for 1 hour delays treatment. The client's blood glucose level could drop further during this time, placing him at risk for irreversible brain damage.
A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?
being obese Obesity is a risk factor for stroke. Other risk factors include a history of ischemic episodes, cardiovascular disease, diabetes mellitus, atherosclerosis of the cranial vessels, hypertension, polycythemia, smoking, hypercholesterolemia, hormonal contraceptive use, emotional stress, family history of stroke, and advancing age. The client's race, gender, and bronchial asthma are not risk factors for stroke.
A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
glucagon During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can't ingest an oral carbohydrate. Epinephrine isn't a treatment for hypoglycemia. Although 50% dextrose is used to treat hypoglycemia, it must be administered I.V. by a skilled healthcare professional. Hydrocortisone takes a relatively long time to raise the blood glucose level and therefore isn't effective in reversing hypoglycemia.
What important considerations would the nurse make when teaching and caring for a client newly diagnosed with diabetes mellitus?
involving the client in the development of the teaching plan and encouraging questions and active participation Actively involving the client in the teaching usually results in better understanding and compliance with the plan of care.
Which intervention is the most critical for a client with myxedema coma?
maintaining a patent airway Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing intervention. Ventilatory support is usually needed. Although myxedema coma is associated with severe hypothermia, a warming blanket shouldn't be used because it may cause vasodilation and shock. Gradual warming with blankets is appropriate. Thyroid replacement is administered I.V., not orally. Although recording intake and output is important, these interventions aren't critical at this time.
A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is:
monitoring the blood glucose level closely. Most TPN solutions contain a high glucose content, placing the client at risk for hyperglycemia. Therefore, the most important nursing action is to monitor the child's blood glucose level closely. A child receiving TPN isn't likely to require vital sign assessment every 30 minutes or elevation of the head of the bed. A daily bath isn't a priority.
The nurse is assigned a client newly diagnosed with type 2 diabetes. Which tasks should the nurse delegate to a unlicensed assistive personnel (UAP)?
reminding the client to check the glucose level before each meal The UAP's role includes reminding clients about interventions that are already in the plan of care. Arranging for an appointment with the dietician is part of the unit clerk's job. Teaching and assessment are part of the licensed nurse's role requiring additional education.
A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?
weight loss, nervousness, and tachycardia Weight loss, nervousness, and tachycardia are signs of hyperthyroidism. Other signs of hyperthyroidism include exophthalmos, diaphoresis, fever, and diarrhea. Weight gain, constipation, lethargy, decreased sweating, and cold intolerance are signs of hypothyroidism.
A nurse is teaching a client about how to recognize when treatment for hypothyroidism is effective. Which statement from the client would indicate that the nurse's teaching has been effective?
"I will start feeling more energetic." Understanding of the treatment for hypothyroidism is shown when the client can identify what changes will signify improvement. An increase in energy will demonstrate that therapy has been effective and the thyroid levels are rising. The other choices are all examples of hyperthyroidism.
A client newly diagnosed with hypothyroidism asks the nurse how long it will be necessary to take the prescribed levothyroxine. What should the nurse tell the client?
"It will be necessary to take the medication for the rest of your life." Thyroid replacement is a lifelong maintenance therapy. The medication is usually given as one dose in the morning. It cannot be tapered or discontinued because the client needs thyroid supplementation to maintain health. The medication cannot be discontinued after the TSH level is normal; the dose will be maintained at the level that normalizes the TSH concentration.
A nurse is teaching a client about type 2 diabetes mellitus. What information would reduce a client's risk of developing this disease?
"Maintain weight within normal limits for your body size and muscle mass." The most important factor predisposing to the development of type 2 diabetes mellitus is obesity. Insulin resistance increases with obesity. Cigarette smoking is not a predisposing factor, but it is a risk factor that increases complications of diabetes mellitus. A high-protein diet does not prevent diabetes mellitus, but it may contribute to hyperlipidemia. Hypertension is not a predisposing factor, but it is a risk factor for developing complications of diabetes mellitus.
The laboratory comes to draw an Hgb A1c. The client asks the nurse what this test represents. Which statement would be correct?
"This test reflects the average blood glucose over a period of approximately 2-3 months." Hgb A1c is a measurement of blood glucose over the life of a red blood cell. It measures the percentage of glycated hemoglobin in the blood. All the other choices do not accurately represent the purpose of the test.
A client with a progressively enlarging neck comes into the clinic. The client mentions that they have been in a foreign country for the previous 3 months and that they didn't eat much while there because they didn't like the food. The client also mentions that they become dizzy when lifting their arms to do normal household chores or when dressing. What endocrine disorder should the nurse expect the physician to diagnose?
A goiter A goiter can result from inadequate dietary intake of iodine associated with changes in foods or malnutrition. It's caused by insufficient thyroid gland production and depletion of glandular iodine. Signs and symptoms of this malfunction include an enlarged thyroid gland, dizziness when raising the arms above the head, dysphagia, and respiratory distress. Signs and symptoms of diabetes mellitus include polydipsia, polyuria, and polyphagia. Signs and symptoms of diabetes insipidus include extreme polyuria (4 to 16 L/day) and symptoms of dehydration (poor tissue turgor, dry mucous membranes, constipation, dizziness, and hypotension). Cushing's syndrome causes buffalo hump, moon face, irritability, emotional lability, and pathologic fractures.
A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia?
Document the client's choice and re-assess pain in 1 hour. A client has the right to choose whether to take medication. The nurse should assess the client's pain regularly and educate the client that taking the medication before the pain gets out of control will be a better pain management plan. The other options do not reflect an understanding of the client's right to choice including the refusal of pain medication.
A client receiving chemotherapy is nauseated and has lost 15 pounds (6.8 kg) in one month. Which nutritional instruction would the nurse include in the plan of care?
Eat frequent but small meals. Small quantities of food offered frequently allow the client to ingest food with the best chance of avoiding nausea. Eating two high protein meals per day may increase nausea. Fluids may distend the stomach and can cause nausea. Extremes in temperature can precipitate nausea.
The nurse is caring for a client with diabetes insipidus (DI). What is the nurse's priority intervention?
Maintaining adequate hydration Maintaining fluid intake is essential in a client with DI. The client is at risk for developing hypovolemic shock because of increased urine output. Weight should be measured daily to monitor fluid balance. Urine specific gravity should be monitored for low osmolality, generally <1.005, due to the body's inability to concentrate urine.
The nurse is caring for a client with type 2 diabetes mellitus. One hour after taking an oral diabetic medication, the client becomes nauseated and vomits. What is the initial action of the nurse?
Monitor blood glucose closely, and assess for signs of hypoglycemia. When a client who has taken an oral antidiabetic agent vomits, the nurse should monitor blood glucose and frequently assess for signs of hypoglycemia. After one hour, most of the medication would have been absorbed. Any food ingested may be lost, and repeating the dose would further lower glucose levels. Giving subcutaneous insulin would also lower glucose levels, causing hypoglycemia. The nurse does not know if the client will develop hypoglycemia, and treatment protocols mean the nurse should not need a healthcare provider prescription to administer glucose tablets if required.
A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family?
Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia. A swallowing assessment will test whether there is complete closure of the epiglottis during swallowing. Incomplete closure indicates that there is not protection of the trachea during oral ingestion of food or fluids. This will necessitate insertion of a nasogastric tube and initiating tube feedings. Tube feedings are less invasive, but this does not answer the underlying basis for insertion of the feeding tube. Demonstrating to the family that the client will choke presents a hazard and is inappropriate when swallowing impairment has been diagnosed. Limited mobility and being susceptible to pneumonia does not answer the underlying reason for the feeding tube
A 79-year-old client has been admitted to the unit. The client is diagnosed with a left hip fracture secondary to a fall, and is scheduled for a left total hip replacement (LTHR). The client's comorbidities are hypertension and diabetes. The client is a full code with no known allergies (NKA). What is the nurse's priority action for this client?
Pain management Addressing acute pain is the priority for this client. Maintaining an acceptable level of pain will allow this client to participate in the plan of care. The other nursing interventions would be lower priorities.
The nurse is reviewing the chart of a client with type 2 diabetes prior to a scheduled appointment. The chart states:Progress notes10/15/160245Client states that he has not been following his prescribed diabetes management program for the past 2 to 3 months. Client is aware of his blood glucose monitoring regimen and diet but has difficulty integrating each into his routines. Client denies recent changes in urinary function, sensation or vision.How can the nurse best determine this client's glycemic control since the last assessment?
Review the results of the client's HbA1c. An HbA1c provides an overview of a person's blood glucose level over the previous 2 to 3 months. Glycosylated hemoglobin values are reported as a percentage of the total hemoglobin within an erythrocyte. The time frame is based on the fact that the usual life span of an erythrocyte is 2 to 3 months. The client's description of health maintenance will not determine adherence to the prescribed schedule. Fasting glucose gives a point-in-time result. A 24-hour food recall is subjective, and does not help the nurse gauge the client's overall adherence.
A client has been admitted with type 2 diabetes mellitus and asks to have the local medicine man come and help decide what traditional aboriginal medicines could help. What are the appropriate nursing interventions based on this client's request?
Suggest that the client inform and discuss with the interprofessional team how traditional therapies could be integrated into the plan of care. Respecting the client's choice is an important ethical principle. Ensuring the safety of the combination of treatments is also part of a nurse's responsibilities.
A nurse explains to a client with thyroid disease that the thyroid gland normally produces
T3, thyroxine (T4), and calcitonin. The thyroid gland normally produces thyroid hormone (T3 and T4) and calcitonin. The pituitary gland produces TSH to regulate the thyroid gland. The hypothalamus gland produces TRH to regulate the pituitary gland.
A nurse is planning care for a client newly diagnosed with diabetes mellitus type 1. Which statement illustrates an appropriate outcome criterion?
The client will correctly demonstrate blood glucose testing prior to discharge. During the planning step of the nursing process, the nurse determines care priorities, develops goals of care, and selects appropriate interventions to achieve these goals. Outcome criterion should be specific and measurable. The other answers have no measurable time frame and are not specific to the disease process of diabetes mellitus.
The nurse is to administer insulin to a client with diabetes mellitus. Which illustration indicates the appropriate syringe to use?
The nurse should administer insulin using an insulin syringe; this syringe is marked in units corresponding to the unit of measure for administering insulin. The syringe with markings up to 1.0 is a tuberculin syringe. The syringes marked up to 3 and 6 mL are used to administer medications to be measured in these larger units of measure.
The nurse is assigned to care for the following clients. Which client should the nurse see first?
a client diagnosed with hypothyroidism and a heart rate of 48 beats per minute A heart rate of 48 beats per minute may have significant implications for cardiac output and hemodynamic stability. Clients with Graves disease usually have a rapid heart rate, but 94 beats per minute is a normal finding. The diabetic client may need sliding-scale coverage, which is not urgent. Clients with Cushing disease frequently have dependent edema.
A client's blood glucose level is 45 mg/dl (2.5 mmol/L). The nurse should be alert for which signs and symptoms?
coma, anxiety, confusion, headache, and cool, moist skin Signs and symptoms of hypoglycemia [indicated by a blood glucose level of 45 mg/dl (2.5 mmol/L)] include anxiety, restlessness, headache, irritability, confusion, diaphoresis, cool skin, tremors, coma, and seizures. Kussmaul respirations, dry skin, hypotension, and bradycardia are signs of diabetic ketoacidosis. Excessive thirst, hunger, hypotension, and hypernatremia are symptoms of diabetes insipidus. Polyuria, polydipsia, polyphagia, and weight loss are classic signs and symptoms of diabetes mellitus.
A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for
decreased body temperature and cold intolerance. Hypothyroidism markedly decreases the metabolic rate, causing a reduced body temperature and cold intolerance. Other signs and symptoms include dyspnea, hypoventilation, bradycardia, hypotension, anorexia, constipation, decreased intellectual function, and depression. Exophthalmos; conjunctival redness; flushed, warm, moist skin; and a systolic murmur at the left sternal border are typical findings in a client with hyperthyroidism.
A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?
restricting fluids to 800 ml/day Excessive release of antidiuretic hormone (ADH) disturbs fluid and electrolyte balance in SIADH. The excessive ADH causes an inability to excrete dilute urine, retention of free water, expansion of extracellular fluid volume, and hyponatremia. Symptomatic treatment begins with restricting fluids to 800 ml/day. Vasopressin is administered to clients with diabetes insipidus a condition in which circulating ADH is deficient. Elevating the head of the bed decreases vascular return and decreases atrial-filling pressure, which increases ADH secretion, thus worsening the client's condition. The client's sodium is low and, therefore, shouldn't be restricted.
Early this morning, a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?
thyroid crisis Thyroid crisis usually occurs in the first 12 hours after thyroidectomy and causes exaggerated signs of hyperthyroidism, such as high fever, tachycardia, and extreme restlessness. Diabetic ketoacidosis is more likely to produce polyuria, polydipsia, and polyphagia. Hypoglycemia is likely to produce weakness, tremors, profuse perspiration, and hunger. Tetany typically causes uncontrollable muscle spasms, stridor, cyanosis, and possibly asphyxia.
A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response?
"Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement." To prevent venous stasis and improve muscle tone, circulation, and respiratory function, the client should be encouraged to move around after surgery. Pain medication will be administered to permit movement. Early ambulation with associated pain management reduces postoperative risk, and all other answers do not reflect this.
A school nurse is assessing an obese 10-year-old child who wants to lose weight. What question will be most important for the nurse to ask to develop a realistic plan of care?
"What kinds of foods do your parents serve at meal times and for snacks?" The greatest determinant of childhood obesity is environmental factors, which include parental diet choices and influence. Children of obese parents are inclined to obesity based on the food served in the family home. The parents' medical conditions and weight concerns are important, but the nurse needs to work with the current situation. Friends can serve as a support system, but the nurse is trying to collect data about the obesity
A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?
"You must avoid coughing, sneezing, and blowing your nose." After a transsphenoidal hypophysectomy, the client must refrain from coughing, sneezing, and blowing the nose for several days to avoid disturbing the surgical graft used to close the wound. The head of the bed must be elevated, not kept flat, to prevent tension or pressure on the suture line. Within 24 hours after a hypophysectomy, transient diabetes insipidus commonly occurs; this calls for increased, not restricted, fluid intake. Visual, not auditory, changes are a potential complication of hypophysectomy.
The nurse has prepared hydromorphone 1 mg I.V. for a client reporting pain 7/10. Just prior to administration, the client requests an oral pain medication instead. What is the priority action by the nurse?
Ask another nurse to witness the waste of the prepared medication into the sink. Hydromorphone is a Schedule II controlled substance and federal law requires accurate records of administration to prevent diversion and misuse of the substance. If a controlled substance is not immediately administered after removing from the locked cabinet, it should be wasted in the sink or approved pharmaceutical waste container with witness and documentation by two nurses. Controlled substances should never be wasted in a sharps container or stored in an unlocked medication drawer as this provides access to the medication for potential misuse. The client's wishes for oral pain management should be honored. The prepared dose should be wasted per facility protocol and the oral medication be administered.
