455 exam 2

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A. A change in the Glasgow Coma Scale score from 13 to 11 B. Diplopia C. A drop in heart rate from 76 to 70/min D. Ataxia

A. A change in the Glasgow Coma Scale score from 13 to 11 Feedback: In a client who has mild TBI, a decrease of 2 points on the Glasgow Coma Scale indicates a decrease in level of consciousness and that the client is risk of a deteriorating neurologic status. Therefore, this finding is the priority to report to the provider.

A nurse is caring for a client who is 1 day postoperative following a subtotal thyroidectomy. The client reports a tingling sensation in the hands, the soles of the feet, and around the lips. For which of the following findings should the nurse assess the client? A. Chvostek's sign B. Babinski's sign C. Brudzinski's sign D. Kernig's sign

A. Chvostek's sign Feedback: The nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. Manifestations of hypocalcemia include numbness and tingling in the hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hr after surgery. To elicit Chvostek's sign, the nurse should tap the client's face at a point just below and in front of the ear. A positive response would be twitching of the ipsilateral (same side only) facial muscles, suggesting neuromuscular excitability due to hypocalcemia

A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following? A. Graham crackers B. 1 tsp sugar C. 4 oz diet soda D. 4 oz skim milk

A. Graham crackers

A client is scheduled for a thoracentesis. What statement indicates further education is necessary? A. "This will be an invasive surgical process into my chest." B. "I will take a deep breath when the large-bore needle is inserted." C. "I will be leaning over a bedside table for the procedure." D. "This procedure will require local anesthetic rather than general anesthetic."

B. "I will take a deep breath when the large-bore needle is inserted." Patient should remain absolutely still to minimize accidental damage from incorrect needle placement

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect? A. Malignant hypertension B. Acetone odor to breath C. Cheyne-Stokes breathing D. Blood glucose level below 40 mg/dL

B. Acetone odor to breath

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. Give morphine IV. B. Administer oxygen therapy. C. Start an IV infusion of lactated Ringer's. D. Initiate cardiac monitoring.

B. Administer oxygen therapy. ABC priority

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Administer a nitrate antihypertensive. B. Assess the client for bladder distention. C. Place the client in a low-Fowler's position. D. Obtain the client's heart rate.

B. Assess the client for bladder distention. Feedback: The client who is experiencing autonomic dysreflexia is at risk for a cerebrovascular accident resulting from severe hypertension. According to the safety and risk reduction priority setting framework, the nurse's initial action should be to place the client in a high-Fowler's position to assist in providing immediate reduction in blood pressure and intracranial pressure.

A nurse is preparing to administer lispro insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take? A. Assess for hypoglycemia 4 hr after the insulin injection. B. Inject the insulin 15 min before a meal. C. Monitor for polyuria. D. Administer with short-acting insulin.

B. Inject the insulin 15 min before a meal.

A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH? A. Osteoarthritis B. Lung cancer C. Liver cirrhosis D. Dyspepsia

B. Lung cancer Feedback: The nurse should ask the client if he has a history of lung cancer because some of the treatment options for small cell lung cancer can cause secretion of antidiuretic hormone. This results in the body retaining water and can cause the syndrome of inappropriate antidiuretic hormone (SIADH).

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority? A. Give the client 15 to 20 g of carbohydrate. B. Monitor the client for hypoglycemia. C. Complete an incident report. D. Notify the nurse manager.

B. Monitor the client for hypoglycemia.

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? A. Eyelets are not visible B. Movement of the trachea toward the unaffected side C. Crepitus in the area above and surrounding the insertion site D. Bubbling of the water in the water seal chamber with exhalation

B. Movement of the trachea toward the unaffected side This is an indication of a tension pneumothorax and should be reported

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? A. Oxygen saturation of 95% B. No fluctuations in the water seal chamber C. No reports of pleuritic chest pain D. Occasional bubbling in the water-seal chamber

B. No fluctuations in the water seal chamber Fluctuations stops when the lung has reexpanded but the nurse should check for other indications of re-expansion:-equal breath sounds bilaterally; fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or suction source is not functioning.

A nurse is caring for a client following surgical treatment for a brain tumor. Which of the following interventions should the nurse take? A. Elevate the head of the bed to 30°. B. Notify the provider for drainage greater than 80 mL/8hr. C. Place the client in a flat, lateral position. D. Provide passive range-of-motion exercises to the neck.

B. Notify the provider for drainage greater than 80 mL/8hr. Feedback: The nurse should notify the provider of drainage greater than 50 mL/8hr because this can indicate a cerebrospinal fluid leak requiring surgical repair.

A nurse is caring for a 54 y/o male patient with DKA. His arterial blood gas shows: pH: 7.28, PaCO2: 30, and HCO3: 18. How would the nurse interpret this ABG result? A. Partially compensated respiratory acidosis B. Partially compensated metabolic acidosis C. Uncompensated respiratory acidosis D. Uncompensated metabolic acidosis

B. Partially compensated metabolic acidosis Feedback:This ABG result shows a partially compensated metabolic acidosis. Kussmaul respiration or deep rapid respirations is a compensatory mechanism that excretes excess carbon dioxide from the blood. This is seen in the patient's ABG result as low PaCO2 level. This is only partially compensated because the pH level has not returned to a homeostatic level yet.

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? A. Assess legs for pallor. B. Perform passive range of motion exercises. C. Place pillows under the client's knees when in bed. D. Massage the calves every shift.

B. Perform passive range of motion exercises. Improves blood return to prevent thrombus formation. Pillows under the knees decrease venous return from the legs increasing DVT risk. Massaging of calves may dislodge possible thrombus causing migration and a PE.

An acute care nurse receives shift report for a client who has increased intracranial pressure. The nurse is told that the client demonstrates decorticate posturing. Which of the following findings should the nurse expect to observe when assessing the client? A. Flexion of the arms B. Pronation of the hands C. Dorsiflexion of the legs D. External rotation of the lower extremities

B. Pronation of the hands Feedback: Flexion of the extremities is an indicator of decorticate posturing.

A nursing is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should nurse include in the teaching? A. Limit intake of potassium-rich foods. B. Restrict sodium intake. C. Increase carbohydrate intake. D. Decrease protein intake.

B. Restrict sodium intake. Feedback: The nurse should recommend the client to restrict sodium intake to control fluid volume. This restriction can range from "no-added-salt" to table foods to a restriction of 2 g/day.

A nurse is caring for a client who is 1 day postoperative following a thyroidectomy and reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take? A. Check the pedal pulses. B. Verify the most recent calcium level. C. Request prescription for a relaxant. D. Administer an oral potassium supplement.

B. Verify the most recent calcium level. Feedback: A client who has had a thyroidectomy is at risk of hypocalcemia due to the possible disruption of the parathyroid gland during surgery. The parathyroid glands are four small glands located inside the thyroid gland that are responsible for calcium regulation. If they are damaged during a thyroidectomy, there is a risk of hypocalcemia. Low calcium levels can be manifested as numbness and tingling of the fingers and around the mouth, muscle spasms (particularly of the hands and feet), and hyperactive reflexes. If a client develops any of these manifestations following a thyroidectomy, the nurse should check the client's latest calcium level. The expected reference range for calcium is 8.5 to 10.5 mg/dL. If the calcium level is low, the provider should be notified, and oral or intravenous calcium replacement should be administered.

A nurse is teaching a female client who has a new prescription for transdermal sumatriptan to treat migraine headaches. Which of the following instructions should the nurse include? A. "Take this medication daily to prevent headaches." B. "Activate the patch 30 minutes after application." C. "Use contraception while taking this medication." D. "You can bathe with the patch in place."

C. "Use contraception while taking this medication." Feedback: Sumatriptan can cause teratogenesis and should not be used during pregnancy.

A nurse is providing teaching about healthy snacks for a client diagnosed with Addison's disease. What snack choice made by the patient demonstrates an understanding of the teaching? A. A banana B. A baked potato C. A turkey and cheese sandwich D. Plain yogurt with peaches

C. A turkey and cheese sandwich Feedback: A turkey and cheese sandwich is high in protein, carbohydrates, and sodium. The client who has Addison's disease requires a diet low in potassium and high in sodium, carbohydrates, and protein. Addison's disease is a hormone deficiency caused by damage to the outer layer of the adrenal gland (adrenal cortex). Addison's disease occurs when the adrenal glands do not produce enough of the hormone cortisol and, in some cases, the hormone aldosterone.

A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect? A. Constipation B. Headache C. Bradycardia D. Hypertension

C. Bradycardia

A nurse is assessing a client who has hyperthyroidism. The nurse should expect the client to report which of the following manifestations? A. Sensitivity to cold B. Constipation C. Frequent mood changes D. Weight gain of 4.5 kg (10 lb) in 3 weeks

C. Frequent mood changes Feedback: Hyperthyroidism develops when the thyroid gland produces an excess of the thyroid hormones that regulate the metabolic rate. Clients experience emotional lability that fluctuates between emotional hyperexcitability and irritability. They often cannot sit quietly.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? A. Clamp the chest tube prior to transferring the client to a wheelchair. B. Disconnect the chest tube from the drainage system during transport. C. Keep the drainage system below the level of the client's chest at all times. D. Empty the collection chamber prior to transport.

C. Keep the drainage system below the level of the client's chest at all times. During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity.

A nurse is reviewing the laboratory data on a client who has a new prescription for heparin for treatment of a pulmonary embolism. Which of the following data should the nurse report to the provider? A. Hematocrit 45% B. Partial thromboplastin time (PTT) 65 seconds C. Platelets 74,000/mm3 D. White blood cell count 8,000/mm3

C. Platelets 74,000/mm3 Normal platelet range 150-450,000. Low platelets places patient at increased bleeding risk while on heparin.

A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the medication? A. Serum sodium 146 mEq/L B. Blood glucose 80 mg/dL C. Urine specific gravity 1.015 D. Blood urea nitrogen (BUN) 15 mg/dL

C. Urine specific gravity 1.015 Feedback: A therapeutic effect of the medication would be urine specific gravity within the expected reference range, which is 1.010-1.025.

A nurse is caring for a 7-year-old child who has an upper respiratory infection and type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction? A. "I will encourage her to drink half a cup of water or sugar-free fluids every 30 minutes." B. "I will report a change in her breathing or any signs of confusion." C. "I will notify the doctor if her temperature is not controlled with acetaminophen." D. "I will continue to check his blood sugar two times every day."

D. "I will continue to check his blood sugar two times every day."

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider? A. Glucocorticoid medications B. Dextrose 5% in 0.45% sodium chloride C. Oral hypoglycemic medications D. 0.9% sodium chloride IV bolus

D. 0.9% sodium chloride IV bolus

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly? A. Absence of fluid in the drainage tubing B. Continuous bubbling within the water seal chamber C. Equal amounts of fluid drainage in each collection chamber D. Fluctuation of the fluid level within the water seal chamber

D. Fluctuation of the fluid level within the water seal chamber Fluid level should fluctuate with inspiration and expiration - rise with inspiration, fall with expiration; opposite happens with positive pressure ventilation.

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? A. Albumin 25% B. Dextran 70 C. Hydroxyethyl glucose D. Mannitol 25%

D. Mannitol 25% Feedback: The nurse should plan to administer mannitol 25%, an osmotic diuretic that lowers intracranial pressure by promoting diuresis.

A nurse is planning care for a client who had a traumatic brain injury and is emerging restlessly from a coma. Which of the following interventions should the nurse include in the plan? A. Apply restraints. B. Administer opioids. C. Darken the room. D. Reduce stimuli.

D. Reduce stimuli. Feedback: The nurse should reduce stimuli by decreasing the number of visitors, speaking calmly, and creating a quiet environment.

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? A. NPH insulin B. Insulin glargine C. Insulin detemir D. Regular insulin

D. Regular insulin

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness

D. Restlessness Feedback: Increased intracranial pressure is a condition in which the pressure of the cerebrospinal fluid or brain matter within the skull exceeds the upper limits for normal. Signs of increasing ICP include restlessness, irritability and confusion along with a change in level of consciousness, or a change in speech pattern.

A nurse in a clinic is reviewing the laboratory values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following laboratory values? A. Serum T3 B. Serum T4 C. Free T4 D. Thyroid stimulating hormone (TSH)

D. Thyroid stimulating hormone (TSH) Feedback: The nurse should anticipate that TSH will be elevated.

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? A. Bradycardia B. Moist mucous membranes C. Bounding peripheral pulses D. Urine specific gravity 1.002

D. Urine specific gravity 1.002 Feedback: The nurse should expect a client who has diabetes insipidus to have diluted urine with a specific gravity less than 1.005.

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. B. Place the client in a supine position. C. Place a warming blanket on the client. D. Use log rolling to reposition the client.

D. Use log rolling to reposition the client. Feedback: Treatment of increased ICP focuses on decreasing the pressure. An important intervention includes positioning the client in a neutral position and avoiding flexion of the neck and hips. In order to avoid hip flexion, the client should be log rolled when repositioned.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? A. Massage over erythematous bony prominences. B. Implement turning schedule every 4 hr. C. Keep the client's skin dry with powder. D. Use pillows to keep heels off the bed surface.

D. Use pillows to keep heels off the bed surface. Feedback: The nurse should keep the heels off the bed to prevent skin breakdown on the client's heels.