A&E 1 Exam 2 questions

14. A student nurse asks what "essential hypertension" is. What response by the registered nurse is best? a) "It means it is caused by another disease." b) "It means it is 'essential' that it be treated." c) "It is hypertension with no specific cause." d) "It refers to severe and life-threatening hypertension."

c) "It is hypertension with no specific cause."

The nurse is teaching a patient with type 2 diabetes mellitus how to prevent diabetic nephropathy. Which statement made by the patient indicates that teaching has been successful? "Smokeless tobacco products decrease the risk of kidney damage." "I can help control my blood pressure by avoiding foods high in salt." "I should have yearly dilated eye examinations by an ophthalmologist." "I will avoid hypoglycemia by keeping my blood sugar above 180 mg/dL.

"I can help control my blood pressure by avoiding foods high in salt." Diabetic nephropathy is a microvascular complication associated with damage to the small blood vessels that supply the glomeruli of the kidney. Risk factors for the development of diabetic nephropathy include hypertension, genetic predisposition, smoking, and chronic hyperglycemia. Patients with diabetes are screened for nephropathy annually with a measurement of the albumin-to-creatinine ratio in urine; a serum creatinine is also needed.

The nurse teaches a 28-yr-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which patient statement requires reinforcement of teaching? "I will avoid adding salt to my food during or after cooking." Incorrect "If I lose weight, I might not need to continue taking medications." "I can lower my blood pressure by switching to smokeless tobacco." "Diet changes can be as effective as taking blood pressure medications."

"I can lower my blood pressure by switching to smokeless tobacco." Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (e.g., the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication.

The nurse is caring for a group of patients. Which patient is at risk of aspiration? A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields

A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube Conditions that increase the risk of aspiration include decreased level of consciousness, difficulty swallowing (dysphagia), and nasogastric intubation with or without tube feeding. With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. Dysphasia is difficulty with speech. Absent bowel sounds and coarse crackles do not increase the risk for aspiration.

When the patient is being examined for venous thromboembolism (VTE) in the calf, what diagnostic test should the nurse expect to teach the patient about first? Duplex ultrasound Contrast venography Magnetic resonance venography Computed tomography venography

Duplex ultrasound The duplex ultrasound is the most widely used test to diagnose VTE. Contrast venography is rarely used now. Magnetic resonance venography is less accurate for calf veins than pelvic and proximal veins. Computed tomography venography may be used but is invasive and much more expensive than the duplex ultrasound.

The nurse is reviewing laboratory results for the clinic patients to be seen today. Which patient meets the diagnostic criteria for diabetes mellitus? A 48-yr-old woman with a hemoglobin A1C of 8.4% A 58-yr-old man with a fasting blood glucose of 111 mg/dL A 68-yr-old woman with a random plasma glucose of 190 mg/dL A 78-yr-old man with a 2-hour glucose tolerance plasma glucose of 184 mg/dL

A 48-yr-old woman with a hemoglobin A1C of 8.4% Criteria for a diagnosis of diabetes mellitus include a hemoglobin A1C of 6.5% or greater, fasting plasma glucose level of 126 mg/dL or greater, 2-hour plasma glucose level of 200 mg/dL or greater during an oral glucose tolerance test, or classic symptoms of hyperglycemia or hyperglycemic crisis with a random plasma glucose of 200 mg/dL or greater.

The nurse instructs a patient with diabetes mellitus about a healthy eating plan. Which statement made by the patient indicates that teaching was successful? "I plan to lose 25 lb this year by following a high-protein diet." "I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." "I should include more fiber in my diet than a person who does not have diabetes." "If I use an insulin pump, I will not need to limit the amount of saturated fat in my diet."

"I may have a hypoglycemic reaction if I drink alcohol on an empty stomach." Eating carbohydrates when drinking alcohol reduces the risk for alcohol-induced hypoglycemia. Intensified insulin therapy, such as the use of an insulin pump, allows considerable flexibility in food selection and can be adjusted for alterations from usual eating and exercise habits. However, saturated fat intake should still be limited to less than 7% of total daily calories. Daily fiber intake of 14 g/1000 kcal is recommended for the general population and for patients with diabetes mellitus. High-protein diets are not recommended for weight loss.

The nurse has taught a patient admitted with diabetes principles of foot care. The nurse evaluates that the patient understands the principles of foot care if the patient makes what statement? "I should only walk barefoot in nice dry weather." "I should look at the condition of my feet every day." "I am lucky my shoes fit so nice and tight because they give me firm support." "When I am allowed up out of bed, I should check the shower water with my toes."

"I should look at the condition of my feet every day." Patients with diabetes mellitus need to inspect their feet daily for broken areas that are at risk for infection and delayed wound healing. Properly fitted (not tight) shoes should be worn at all times. Water temperature should be tested with the hands first.

The nurse teaches a patient recently diagnosed with type 1 diabetes mellitus about insulin administration. Which statement by the patient requires an intervention by the nurse? "I will discard any insulin bottle that is cloudy in appearance." "The best injection site for insulin administration is in my abdomen." "I can wash the site with soap and water before insulin administration." "I may keep my insulin at room temperature (75oF) for up to 1 month."

"I will discard any insulin bottle that is cloudy in appearance." Intermediate-acting insulin and combination-premixed insulin will be cloudy in appearance. Routine hygiene such as washing with soap and rinsing with water is adequate for skin preparation for the patient during self-injections. Insulin vials that the patient is currently using may be left at room temperature for up to 4 weeks unless the room temperature is higher than 86°F (30°C) or below freezing

The nurse is teaching a patient with type 2 diabetes mellitus about exercise to help control blood glucose. The nurse knows the patient understands when the patient elicits which exercise plan? "I want to go fishing for 30 minutes each day; I will drink fluids and wear sunscreen." "I will go running each day when my blood sugar is too high to bring it back to normal." "I will plan to keep my job as a teacher because I get a lot of exercise every school day." "I will take a brisk 30-minute walk 5 days per week and do resistance training three times a week."

"I will take a brisk 30-minute walk 5 days per week and do resistance training three times a week." The best exercise plan for the person with type 2 diabetes is for 30 minutes of moderate activity 5 days per week and resistance training three times a week. Brisk walking is moderate activity. Fishing and teaching are light activity, and running is considered vigorous activity.

A patient admitted with type 2 diabetes asks the nurse what "type 2" means. What is the most appropriate response by the nurse? "With type 2 diabetes, the body of the pancreas becomes inflamed." "With type 2 diabetes, the patient is totally dependent on an outside source of insulin." "With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." "With type 2 diabetes, the body produces autoantibodies that destroy β-cells in the pancreas."

"With type 2 diabetes, insulin secretion is decreased, and insulin resistance is increased." In type 2 diabetes mellitus, the secretion of insulin by the pancreas is reduced and/or the cells of the body become resistant to insulin. The pancreas becomes inflamed with pancreatitis. The patient is totally dependent on exogenous insulin and may have had autoantibodies destroy the β-cells in the pancreas with type 1 diabetes mellitus.

The patient received regular insulin 10 units subcutaneously at 8:30 PM for a blood glucose level of 253 mg/dL. The nurse plans to monitor this patient for signs of hypoglycemia at which time related to the insulin's peak action? 8:40 PM to 9:00 PM 9:00 PM to 11:30 PM 10:30 PM to 1:30 AM 12:30 AM to 8:30 AM

10:30 PM to 1:30 AM Regular insulin exerts peak action in 2 to 5 hours, making the patient most at risk for hypoglycemia between 10:30 PM and 1:30 AM. Rapid-acting insulin's onset is between 10 and 30 minutes with peak action and hypoglycemia most likely to occur between 9:00 PM and 11:30 PM. With intermediate acting insulin, hypoglycemia may occur from 12:30 AM to 8:30 AM.

Which patient with type 1 diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness? A 58-yr-old patient with diabetic retinopathy A 73-yr-old patient who takes propranolol (Inderal) A 19-yr-old patient who is on the school track team A 24-yr-old patient with a hemoglobin A1C of 8.9%

A 73-yr-old patient who takes propranolol (Inderal) Hypoglycemic unawareness is a condition in which a person does not experience the warning signs and symptoms of hypoglycemia until the person becomes incoherent and combative or loses consciousness. Hypoglycemic awareness is related to autonomic neuropathy of diabetes that interferes with the secretion of counterregulatory hormones that produce these symptoms. Older patients and patients who use β-adrenergic blockers (e.g., propranolol) are at risk for hypoglycemic unawareness.

The nurse is assigned to the care of a patient diagnosed with type 2 diabetes. In formulating a teaching plan that encourages the patient to actively participate in management of the diabetes, what should be the nurse's initial intervention? Assess patient's perception of what it means to have diabetes. Ask the patient to write down current knowledge about diabetes. Set goals for the patient to actively participate in managing his diabetes. Assume responsibility for all of the patient's care to decrease stress level.

Assess patient's perception of what it means to have diabetes. For teaching to be effective, the first step is to assess the patient. Teaching can be individualized after the nurse is aware of what a diagnosis of diabetes means to the patient. After the initial assessment, current knowledge can be assessed, and goals should be set with the patient. Assuming responsibility for all of the patient's care will not facilitate the patient's health.

A patient with type 2 diabetes has a urinary tract infection (UTI), is difficult to arouse, and has a blood glucose of 642 mg/dL. When the nurse assesses the urine, there are no ketones present. What nursing action is appropriate at this time? Routine insulin therapy and exercise Administer a different antibiotic for the UTI. Cardiac monitoring to detect potassium changes Administer IV fluids rapidly to correct dehydration.

Cardiac monitoring to detect potassium changes This patient has manifestations of hyperosmolar hyperglycemic syndrome (HHS). Cardiac monitoring will be needed because of the changes in the potassium level related to fluid and insulin therapy and the osmotic diuresis from the elevated serum glucose level. Routine insulin would not be enough, and exercise could be dangerous for this patient. Extra insulin will be needed. The type of antibiotic will not affect HHS. There will be a large amount of IV fluid administered, but it will be given slowly because this patient is older and may have cardiac or renal compromise, requiring hemodynamic monitoring to avoid fluid overload during fluid replacement.

The nurse is assisting a patient with newly diagnosed type 2 diabetes to learn dietary planning as part of the initial management of diabetes. The nurse would encourage the patient to limit intake of which foods to help reduce the percent of fat in the diet? Cheese Broccoli Chicken Oranges

Cheese Cheese is a product derived from animal sources and is higher in fat and calories than vegetables, fruit, and poultry. Excess fat in the diet is limited to help avoid macrovascular changes.

The nurse has been teaching a patient with diabetes mellitus how to perform self-monitoring of blood glucose (SMBG). During evaluation of the patient's technique, the nurse identifies a need for additional teaching when the patient does what? Chooses a puncture site in the center of the finger pad Washes hands with soap and water to cleanse the site to be used Warms the finger before puncturing the finger to obtain a drop of blood Tells the nurse that the result of 110 mg/dL indicates good control of diabetes

Chooses a puncture site in the center of the finger pad The patient should select a site on the sides of the fingertips, not on the center of the finger pad because this area contains many nerve endings and would be unnecessarily painful. Washing hands, warming the finger, and knowing the results that indicate good control all show understanding of the teaching.

Which assessment findings of the left lower extremity will the nurse identify as consistent with arterial occlusion (select all that apply.)? Edematous Cold and mottled Complaints of paresthesia Pulse not palpable with Doppler Capillary refill less than three seconds Erythema and warmer than right lower extremity

Cold and mottled Complaints of paresthesia Pulse not palpable with Doppler Arterial occlusion may result in loss of limb if not timely revascularized. When an artery is occluded, perfusion to the extremity is impaired or absent. On assessment, the nurse would note a cold, mottled extremity with impaired sensation or numbness. The pulse would not be identified, even with a Doppler. In contrast, the nurse would find edema, erythema, and increased warmth in the presence of a venous occlusion (deep vein thrombosis). Capillary refill would be greater than 3 seconds in an arterial occlusion and less than 3 seconds with a venous occlusion.

A patient is newly diagnosed with type 1 diabetes and reports a headache, changes in vision, and being anxious but does not have a portable blood glucose monitor present. Which action should the nurse advise her to take? Eat a piece of pizza. Drink some diet pop. Eat 15 g of simple carbohydrates. Take an extra dose of rapid-acting insulin.

Eat 15 g of simple carbohydrates. When the patient with type 1 diabetes is unsure about the meaning of the symptoms she is experiencing, she should treat herself for hypoglycemia to prevent seizures and coma from occurring. She should also be advised to check her blood glucose as soon as possible. The fat in the pizza and the diet pop would not allow the blood glucose to increase to eliminate the symptoms. The extra dose of rapid-acting insulin would further decrease her blood glucose.

The nurse is evaluating a patient diagnosed with type 2 diabetes mellitus. Which symptom reported by the patient correlates with the diagnosis? Excessive thirst Gradual weight gain Overwhelming fatigue Recurrent blurred vision

Excessive thirst The classic symptoms of diabetes are polydipsia (excessive thirst), polyuria, (excessive urine output), and polyphagia (increased hunger). Weight gain, fatigue, and blurred vision may all occur with type 2 diabetes, but are not classic manifestations.

The nurse caring for a patient hospitalized with diabetes mellitus would look for which laboratory test result to obtain information on the patient's past glucose control? Prealbumin level Urine ketone level Fasting glucose level Glycosylated hemoglobin level

Glycosylated hemoglobin level A glycosylated hemoglobin level detects the amount of glucose that is bound to red blood cells (RBCs). When circulating glucose levels are high, glucose attaches to the RBCs and remains there for the life of the blood cell, which is approximately 120 days. Thus, the test can give an indication of glycemic control over approximately 2 to 3 months. The prealbumin level is used to establish nutritional status and is unrelated to past glucose control. The urine ketone level will only show that hyperglycemia or starvation is probably currently occurring. The fasting glucose level only indicates current glucose control.

The nurse is reviewing laboratory results for a patient with a 15-year history of type 2 diabetes. Which result reflects the expected pattern accompanying macrovascular disease as a complication of diabetes? Increased triglyceride levels Increased high-density lipoproteins (HDL) Decreased low-density lipoproteins (LDL) Decreased very-low-density lipoproteins (VLDL)

Increased triglyceride levels Macrovascular complications of diabetes include changes to large- and medium-sized blood vessels. They include cerebrovascular, cardiovascular, and peripheral vascular disease. Increased triglyceride levels are associated with these macrovascular changes. Increased HDL, decreased LDL, and decreased VLDL are positive in relation to atherosclerosis development.

A patient, admitted with diabetes mellitus, has a glucose level of 380 mg/dL and a moderate level of ketones in the urine. As the nurse assesses for signs of ketoacidosis, which respiratory pattern would the nurse expect to find? Central apnea Hypoventilation Kussmaul respirations Cheyne-Stokes respirations

Kussmaul respirations In diabetic ketoacidosis, the lungs try to compensate for the acidosis by blowing off volatile acids and carbon dioxide. This leads to a pattern of Kussmaul respirations, which are deep and nonlabored. Central apnea occurs because the brain temporarily stops sending signals to the muscles that control breathing, which is unrelated to ketoacidosis. Hypoventilation and Cheyne-Stokes respirations do not occur with ketoacidosis.

The nurse is teaching a patient who has diabetes about vascular complications of diabetes. What information is appropriate for the nurse to include? Macroangiopathy does not occur in type 1 diabetes but rather in type 2 diabetics who have severe disease. Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Renal damage resulting from changes in large- and medium-sized blood vessels can be prevented by careful glucose control. Macroangiopathy causes slowed gastric emptying and the sexual impotency experienced by a majority of patients with diabetes.

Microangiopathy is specific to diabetes and most commonly affects the capillary membranes of the eyes, kidneys, and skin. Microangiopathy occurs in diabetes mellitus. When it affects the eyes, it is called diabetic retinopathy. When the kidneys are affected, the patient has nephropathy. When the skin is affected, it can lead to diabetic foot ulcers. Macroangiopathy can occur in either type 1 or type 2 diabetes and contributes to cerebrovascular, cardiovascular, and peripheral vascular disease. Sexual impotency and slowed gastric emptying result from microangiopathy and neuropathy.

A patient with diabetes mellitus is scheduled for a fasting blood glucose level at 8:00 AM. The nurse instructs the patient to only drink water after what time? 6:00 PM on the evening before the test Midnight before the test 4:00 AM on the day of the test 7:00 AM on the day of the test

Midnight before the test Typically, a patient is ordered to be NPO for 8 hours before a fasting blood glucose level. For this reason, the patient who has a lab draw at 8:00 AM should not have any food or beverages containing any calories after midnight.

A patient with diabetes mellitus who has multiple infections every year needs a mitral valve replacement. What is the most important preoperative teaching the nurse should provide to prevent a cardiac infection postoperatively? Avoid sick people and wash hands. Obtain comprehensive dental care. Maintain hemoglobin A1C below 7%. Coughing and deep breathing with splinting

Obtain comprehensive dental care. A person with diabetes is at high risk for postoperative infections. The most important preoperative teaching to prevent a postoperative infection in the heart is to have the patient obtain comprehensive dental care because the risk of septicemia and infective endocarditis increases with poor dental health. Avoiding sick people, hand washing, maintaining hemoglobin A1C below 7%, and coughing and deep breathing with splinting would be important for any type of surgery but are not the priority for this patient with mitral valve replacement.

The patient reports tenderness when she touches her leg over a vein. The nurse assesses warmth and a palpable cord in the area. The nurse knows the patient needs treatment to prevent which sequela? Pulmonary embolism Pulmonary hypertension Post-thrombotic syndrome Venous thromboembolism

Venous thromboembolism The clinical manifestations are characteristic of a superficial vein thrombosis. If untreated, the clot may extend to deeper veins, and venous thromboembolism may occur. Pulmonary embolism, pulmonary hypertension, and postthrombotic syndrome are the sequelae of venous thromboembolism.

The newly diagnosed patient with type 2 diabetes has been prescribed metformin. What should the nurse teach the patient to best explain how this medication works? Increases insulin production from the pancreas Slows the absorption of carbohydrate in the small intestine Reduces glucose production by the liver and enhances insulin sensitivity Increases insulin release from the pancreas, inhibits glucagon secretion, and decreases gastric emptying

Reduces glucose production by the liver and enhances insulin sensitivity Metformin is a biguanide that reduces glucose production by the liver and enhances the tissue's insulin sensitivity. Sulfonylureas and meglitinides increase insulin production from the pancreas. α-Glucosidase inhibitors slow the absorption of carbohydrate in the intestine. Glucagon-like peptide receptor agonists increase insulin synthesis and release from the pancreas, inhibit glucagon secretion, and decrease gastric emptying.

The patient has chronic venous insufficiency and a venous ulcer. The unlicensed assistive personnel (UAP) decides to apply compression stockings because that is what patients 'always' have ordered. Which assessment finding would indicate the application of compression stockings could harm the patient? Rest pain High blood pressure Elevated blood sugar Dry, itchy, flaky skin

Rest pain Rest pain occurs as peripheral artery disease (PAD) progresses and involves multiple arterial segments. Compression stockings should not be used on patients with PAD. Elevated blood glucose, possibly indicating uncontrolled diabetes mellitus, and hypertension may or may not indicate arterial problems. Dry, itchy, flaky skin indicates venous insufficiency. The RN should be the one to obtain the order and instruct the UAP to apply compression stockings if they are ordered.

A patient is admitted with diabetes mellitus, malnutrition cellulitis, and a potassium level of 5.6 mEq/L. The nurse understands that what could be contributing factors for this laboratory result (select all that apply.)? The level may be increased as a result of dehydration that accompanies hyperglycemia. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. The level is consistent with renal insufficiency that can develop with renal nephropathy. The patient may be excreting extra sodium and retaining potassium because of malnutrition. This level demonstrates adequate treatment of the cellulitis and effective serum glucose control.

The level may be increased as a result of dehydration that accompanies hyperglycemia. The level may be raised as a result of metabolic ketoacidosis caused by hyperglycemia. The level is consistent with renal insufficiency that can develop with renal nephropathy. The additional stress of cellulitis may lead to an increase in the patient's serum glucose levels. Dehydration may cause hemoconcentration, resulting in elevated serum readings. The kidneys may have difficulty excreting potassium if renal insufficiency exists. Finally, the nurse must consider the potential for metabolic ketoacidosis because potassium will leave the cell when hydrogen enters in an attempt to compensate for a low pH. Malnutrition does not cause sodium excretion accompanied by potassium retention. Thus, it is not a contributing factor to this patient's potassium level. The elevated potassium level does not demonstrate adequate treatment of cellulitis or effective serum glucose control.

42. The nurse is monitoring a client with hypoglycemia. Glucagon provides which function? a) It enhances the activity of insulin, restoring blood glucose levels to normal more quickly after a high-calorie meal. b) It is a storage form of glucose and can be broken down for energy when blood glucose levels are low. c) It converts excess glucose into glycogen, lowering blood glucose levels in times of excess. d) It prevents hypoglycemia by promoting release of glucose from liver storage sites.

d) It prevents hypoglycemia by promoting release of glucose from liver storage sites.

43. Which client is at greatest risk for undiagnosed diabetes mellitus? a) Young, muscular white man b) Young African-American man c) Middle-aged Asian woman d) Middle-aged American Indian woman

d) Middle-aged American Indian woman

18. A nursing student is caring for a client with an abdominal aneurysm. What action by the student requires the registered nurse to intervene? a) Assesses the client for back pain b) Auscultates over abdominal bruit c) Measures the abdominal girth d) Palpates the abdomen in four quadrants

d) Palpates the abdomen in four quadrants

24. A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the client's polyuria? a) Serum sodium: 163 mEq/L b) Serum creatinine: 1.6 mg/dL c) Presence of urine ketones d) Serum osmolarity: 375 mOsm/kg

d) Serum osmolarity: 375 mOsm/kg

37. A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? a) Serum chloride level of 98 mmol/L b) Serum calcium level of 8.8 mg/dL c) Serum sodium level of 132 mmol/L d) Serum potassium level of 2.5 mmol/L

d) Serum potassium level of 2.5 mmol/L

50. A client was admitted with diabetic ketoacidosis (DKA). Which manifestations does the nurse monitor the client most closely for? a) Shallow slow respirations and respiratory alkalosis b) Decreased urine output and hyperkalemia c) Tachycardia and orthostatic hypotension d) Peripheral edema and dependent pulmonary crackles

c) Tachycardia and orthostatic hypotension

47. Three hours after surgery, the nurse notes that the breath of the client with type 1 diabetes has a "fruity" odor. Which is the nurse's best first action? a) Document the finding in the client's chart. b) Increase the IV fluid flow rate. c) Test the serum for ketone bodies. d) Perform pulmonary hygiene.

c) Test the serum for ketone bodies.

46. The nurse is teaching a client with diabetes about self-care. Which activity does the nurse teach that can decrease insulin needs? a) Reducing intake of liquids to 2 L/day b) Eating animal organ meats high in insulin c) Limiting carbohydrate intake to 100 g/day d) Walking 1 mile each day

d) Walking 1 mile each day

The nurse evaluates that discharge teaching for a patient hospitalized with pneumonia has been effective when the patient makes which statement about measures to prevent a relapse? "I will seek immediate medical treatment for any upper respiratory infections." "I should continue to do deep breathing and coughing exercises for at least 12 weeks." "I will increase my food intake to 2400 calories a day to keep my immune system well." "I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution."

"I must have a follow-up chest x-ray in 6 to 8 weeks to evaluate the pneumonia's resolution." The follow-up chest x-ray examination will be done in 6 to 8 weeks to evaluate pneumonia resolution. A patient should seek medical treatment for upper respiratory infections that persist for more than 7 days. It may be important for the patient to continue with coughing and deep breathing exercises for 6 to 8 weeks, not 12 weeks, until all of the infection has cleared from the lungs. Increased fluid intake, not caloric intake, is required to liquefy secretions.

A patient with varicose veins has been prescribed compression stockings. Which nursing instruction would be most appropriate? "Try to keep your stockings on 24 hours a day, as much as possible." "While you're still lying in bed in the morning, put on your stockings." "Dangle your feet at your bedside for 5 minutes before putting on your stockings." "Your stockings will be most effective if you can remove them for a few minutes several times a day."

"While you're still lying in bed in the morning, put on your stockings." The patient with varicose veins should apply stockings in bed before rising in the morning. Stockings should not be worn continuously and should not be removed several times daily. Dangling at the bedside before application is likely to decrease their effectiveness.

Which person should the nurse identify as having the highest risk for abdomenal aortic aneurysm? A 70-yr-old man with high cholesterol and hypertension A 40-yr-old woman with obesity and metabolic syndrome A 60-yr-old man with renal insufficiency who is physically inactive A 65-yr-old woman with hyperhomocysteinemia and substance abuse

A 70-yr-old man with high cholesterol and hypertension The most common etiology of descending abdominal aortic aneurysm (AAA) is atherosclerosis. Male gender, age 65 years or older, and tobacco use are the major risk factors for AAAs of atherosclerotic origin. Other risk factors include the presence of coronary or peripheral artery disease, high blood pressure, and high cholesterol.

The nurse is caring for a patient with a nursing diagnosis of hyperthermia related to pneumonia. What assessment data does the nurse obtain that correlates with this nursing diagnosis (select all that apply.)? A temperature of 101.4°F Heart rate of 120 beats/min Respiratory rate of 20 breaths/min A productive cough with yellow sputum Reports of unable to have a bowel movement for 2 days

A temperature of 101.4°F Heart rate of 120 beats/min A productive cough with yellow sputum A fever is an inflammatory response related to the infectious process. A productive cough with discolored sputum (which should be clear) is an indication that the patient has pneumonia. A respiratory rate of 20 breaths/min is within normal range. Inability to have a bowel movement is not related to a diagnosis of pneumonia. A heart rate of 120 beats/min indicates that there is increased metabolism due to the fever and is related to the diagnosis of pneumonia.

A nurse is caring for a patient with a diagnosis of deep venous thrombosis (DVT). The patient has an order to receive 30 mg enoxaparin (Lovenox). Which injection site should the nurse use to administer this medication safely? Buttock, upper outer quadrant Abdomen, anterior-lateral aspect Back of the arm, 2 inches away from a mole Anterolateral thigh, with no scar tissue nearby

Abdomen, anterior-lateral aspect Enoxaparin (Lovenox) is a low-molecular-weight (LMW) heparin that is given as a deep subcutaneous injection in the right and left anterolateral abdomen. All subcutaneous injections should be given away from scars, lesions, or moles.

A 39-yr-old woman with a history of smoking and oral contraceptive use is admitted with a venous thromboembolism (VTE) and prescribed unfractionated heparin. What laboratory test should the nurse review to evaluate the expected effect of the heparin? Platelet count Activated clotting time (ACT) International normalized ratio (INR) Activated partial thromboplastin time

Activated partial thromboplastin time Unfractionated heparin can be given by continuous IV for VTE treatment. When given IV, heparin requires frequent laboratory monitoring of clotting status as measured by activated partial thromboplastin time (aPTT). Platelet counts can decrease as an adverse reaction to heparin.

The nurse is reviewing the laboratory test results for a 68-yr-old patient whose warfarin (Coumadin) therapy was terminated during the preoperative period. On postoperative day 2, the international normalized ratio (INR) result is 2.7. Which action by the nurse is most appropriate? Hold the daily dose of warfarin. Administer the daily dose of warfarin. Teach the patient signs and symptoms of bleeding. Call the physician to request an increased dose of warfarin.

Administer the daily dose of warfarin. The therapeutic range for INR is 2.0 to 3.0 for many clinical diagnoses. To maintain therapeutic values, the nurse will administer the medication as ordered. Holding the medication would lower the INR, which would increase the risk of clot formation. Conversely, the higher the INR is, the more prolonged the clotting time. Calling the health care provider is not indicated. Although teaching is important, administering the medication is a higher priority at this time.

A patient with critical limb ischemia had peripheral artery bypass surgery to improve circulation. What nursing care should be provided on postoperative day 1? Keep patient on bed rest. Assist patient to walk several times. Have patient sit in the chair several times. Place patient on their side with knees flexed.

Assist patient to walk several times. To avoid blockage of the graft or stent, the patient should walk several times on postoperative day 1 and subsequent days. Having the patient's knees flexed for sitting in a chair or in bed increase the risk of venous thrombosis and may place stress on the suture lines.

The nurse is caring for a patient admitted with a history of hypertension. The patient's medication history includes hydrochlorothiazide daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy? Weight loss of 2 lb BP 128/86 mm Hg Absence of ankle edema Output of 600 mL per 8 hours

BP 128/86 mm Hg Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Because the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.

The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? Basilar crackles Oxygen saturation of 85% Presence of greenish sputum Respiratory rate of 28 breaths/min

Basilar crackles The presence of adventitious breath sounds indicates that there is accumulation of secretions in the lower airways. This would be consistent with a nursing diagnosis of ineffective airway clearance because the patient is retaining secretions. The rapid respiratory rate, low oxygen saturation, and presence of greenish sputum may occur with a lower respiratory problem but do not definitely support the nursing diagnosis of ineffective airway clearance.

A patient was admitted for possible ruptured aortic aneurysm. No back pain was reported. Ten minutes later, the nurse notes sinus tachycardia 138 beats/min, blood pressure is palpable at 65 mm Hg, increasing waist circumference, and no urine output. How should the nurse interpret the findings? Tamponade will soon occur. The renal arteries are involved. Perfusion to the legs is impaired. Bleeding into the abdomen is likely.

Bleeding into the abdomen is likely. The lack of back pain indicates the patient is most likely exsanguinating into the abdominal space, and the bleeding is likely to continue without surgical repair. A blockade of the blood flow will not occur in the abdominal space as it would in the retroperitoneal space, where surrounding anatomic structures may control the bleeding. The lack of urine output does not indicate renal artery involvement but that the bleeding is occurring above the renal arteries, which decreases the blood flow to the kidneys. There are no assessment data indicating decreased perfusion to the legs.

The nurse is caring for a patient who has been receiving warfarin (Coumadin) and digoxin (Lanoxin) as treatment for atrial fibrillation. Because the warfarin has been discontinued before surgery, the nurse should diligently assess the patient for which complication early in the postoperative period until the medication is resumed? Decreased cardiac output Increased blood pressure Cerebral or pulmonary emboli Excessive bleeding from incision or IV sites

Cerebral or pulmonary emboli Warfarin is an anticoagulant that is used to prevent thrombi from forming on the walls of the atria during atrial fibrillation. When the medication is terminated, thrombi could again form. If one or more thrombi detach from the atrial wall, they could travel as cerebral emboli from the left atrium or pulmonary emboli from the right atrium.

The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-yr-old obese female patient admitted with heart failure. Which action by the UAP will require the nurse to intervene? Waiting 2 minutes after position changes to take orthostatic pressures Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second Taking the blood pressure with the patient's arm at the level of the heart Taking a forearm blood pressure because the largest cuff will not fit the patient's upper arm

Deflating the blood pressure cuff at a rate of 8 to 10 mm Hg per second The cuff should be deflated at a rate of 2 to 3 mm Hg per second. The arm should be supported at the level of the heart for accurate blood pressure measurements. Using a cuff that is too small causes a falsely high reading and too large causes a falsely low reading. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.

A 73-yr-old man with dementia has a venous ulcer related to chronic venous insufficiency. The nurse should provide teaching on which type of diet for this patient and his caregiver? Low-fat diet High-protein diet Calorie-restricted diet High-carbohydrate diet

High-protein diet A patient with a venous ulcer should have a balanced diet with adequate protein, calories, and micronutrients; this type of diet is essential for healing. Nutrients most important for healing include protein, vitamins A and C, and zinc. Foods high in protein (e.g., meat, beans, cheese, tofu), vitamin A (green leafy vegetables), vitamin C (citrus fruits, tomatoes, cantaloupe), and zinc (meat, seafood) must be provided. Restricting fat or calories is not helpful for wound healing or in patients of normal weight. For overweight individuals with no active venous ulcer, a weight-loss diet should be considered.

The nurse is caring for a patient with a recent history of deep vein thrombosis (DVT) who is scheduled for an emergency appendectomy. Vitamin K is ordered for immediate administration. The international normalized ratio (INR) value is 1.0. Which nursing action is most appropriate? Administer the medication as ordered. Hold the medication and record in the electronic medical record. Hold the medication until the lab result is repeated to verify results. Administer the medication and seek an increased dose from the health care provider.

Hold the medication and record in the electronic medical record. Vitamin K is the antidote to warfarin (Coumadin), which the patient has most likely been taking before admission for treatment of DVT. Warfarin is an anticoagulant that impairs the ability of the blood to clot. Therefore, it may be necessary to give vitamin K before surgery to reduce the risk of hemorrhage. However, the INR value is normal, and vitamin K is not required, so the medication would be held and recorded in the electronic medical record.

The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism? Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.

Hypertension promotes atherosclerosis and damage to the walls of the arteries. Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, when atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.

A 32-yr-old woman is prescribed diltiazem (Cardizem) for Raynaud's phenomenon. To evaluate the effectiveness of the medication, which assessment will the nurse perform? Improved skin turgor Decreased cardiac rate Improved finger perfusion Decreased mean arterial pressure

Improved finger perfusion Raynaud's phenomenon is an episodic vasospastic disorder of small cutaneous arteries, most frequently involving the fingers and toes. Diltiazem (Cardizem) is a calcium channel blocker that relaxes smooth muscles of the arterioles by blocking the influx of calcium into the cells, thus reducing the frequency and severity of vasospastic attacks. Perfusion to the fingertips is improved, and vasospastic attacks are reduced. Diltiazem may decrease heart rate and blood pressure, but that is not the purpose in Raynaud's phenomenon. Skin turgor is most often a reflection of hydration status.

The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? Humidify the oxygen as able. Administer cough suppressant q4hr. Teach patient to splint the affected area. Increase fluid intake to 3 L/day if tolerated.

Increase fluid intake to 3 L/day if tolerated. Although several interventions may help the patient expectorate mucus, the highest priority should be on increasing fluid intake, which will liquefy the secretions so that the patient can expectorate them more easily. Humidifying the oxygen is also helpful but is not the primary intervention. Teaching the patient to splint the affected area may also be helpful in decreasing discomfort but does not assist in expectoration of thick secretions.

The nurse is performing a respiratory assessment for a patient admitted with pneumonia. Which clinical manifestation should the nurse expect to find? Hyperresonance on percussion Vesicular breath sounds in all lobes Increased vocal fremitus on palpation Fine crackles in all lobes on auscultation

Increased vocal fremitus on palpation A typical physical examination finding for a patient with pneumonia is increased vocal fremitus on palpation. Other signs of pulmonary consolidation include bronchial breath sounds, egophony, and crackles in the affected area. With pleural effusion, there may be dullness to percussion over the affected area.

The nurse is teaching a women's group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply.)? Lose weight. Limit nuts and seeds. Limit sodium and fat intake. Increase fruits and vegetables. Exercise 30 minutes most days.

Limit sodium and fat intake. Increase fruits and vegetables. Exercise 30 minutes most days. Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Nuts and seeds and dried beans are used for protein intake. Weight loss may or may not be necessary for the individual.

The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? Maintain adequate fluid intake. Maintain a 30-degree elevation. Splint the chest when coughing. Maintain a semi-Fowler's position. Instruct patient to cough at end of exhalation.

Maintain adequate fluid intake. Splint the chest when coughing. Instruct patient to cough at end of exhalation. Maintaining adequate fluid intake liquefies secretions, allowing easier expectoration. The nurse should instruct the patient to splint the chest while coughing. This will reduce discomfort and allow for a more effective cough. Coughing at the end of exhalation promotes a more effective cough. The patient should be positioned in an upright sitting position (high Fowler's) with head slightly flexed.

The nurse is developing a plan of care for a patient with metastatic lung cancer and a 60-pack-year history of cigarette smoking. For what should the nurse monitor this patient? Cough reflex Mucociliary clearance Reflex bronchoconstriction Ability to filter particles from the air

Mucociliary clearance Smoking decreases the ciliary action in the tracheobronchial tree, resulting in impaired clearance of respiratory secretions and particles, chronic cough, and frequent respiratory infections.

The nurse is admitting a patient with a diagnosis of pulmonary embolism. What risk factors is a priority for the nurse to assess (select all that apply.)? Obesity Pneumonia Malignancy Cigarette smoking Prolonged air travel

Obesity Malignancy Cigarette smoking Prolonged air travel An increased risk of pulmonary embolism is associated with obesity, malignancy, heavy cigarette smoking, and prolonged air travel with reduced mobility. Other risk factors include deep vein thrombosis, immobilization, and surgery within the previous 3 months, oral contraceptives and hormone therapy, heart failure, pregnancy, and clotting disorders.

While ambulating a patient with metastatic lung cancer, the nurse observes a drop in oxygen saturation from 93% to 86%. Which nursing action is most appropriate? Continue with ambulation. Obtain a physician's order for arterial blood gas. Obtain a physician's order for supplemental oxygen. Move the oximetry probe from the finger to the earlobe.

Obtain a physician's order for supplemental oxygen. An oxygen saturation level that drops below 90% with activity indicates that the patient is not tolerating the exercise and needs to use supplemental oxygen. The patient will need to rest to resaturate. ABGs or moving the probe will not be needed as the pulse oximeter was working at the beginning of the walk.

The nurse is caring for a patient with pneumonia unresponsive to two different antibiotics. Which action is most important for the nurse to complete before administering a newly prescribed antibiotic? Teach the patient to cough and deep breathe. Take the temperature, pulse, and respiratory rate. Obtain a sputum specimen for culture and Gram stain. Check the patient's oxygen saturation by pulse oximetry.

Obtain a sputum specimen for culture and Gram stain. A sputum specimen for culture and Gram stain to identify the organism should be obtained before beginning antibiotic therapy. However, antibiotic administration should not be delayed if a specimen cannot be readily obtained because delays in antibiotic therapy can increase morbidity and mortality risks.

A patient was just diagnosed with acute arterial ischemia in the left leg secondary to atrial fibrillation. Which early clinical manifestation must be reported to the physician immediately to save the patient's limb? Paralysis Paresthesia Cramping Referred pain

Paresthesia The physician must be notified immediately if any of the six Ps of acute arterial ischemia occur to prevent ischemia from quickly progressing to tissue necrosis and gangrene. The six Ps are paresthesia, pain, pallor, pulselessness, and poikilothermia, with paralysis being a very late sign indicating the death of nerves to the extremity. Crampy leg sensation is more common with varicose veins. The pain is not referred.

A 67-yr-old man with peripheral artery disease is seen in the primary care clinic. Which symptom reported by the patient would indicate to the nurse that the patient is experiencing intermittent claudication? Patient complains of chest pain with strenuous activity. Patient says muscle leg pain occurs with continued exercise. Patient has numbness and tingling of all his toes and both feet. Patient states the feet become red if he puts them in a dependent position.

Patient says muscle leg pain occurs with continued exercise. Intermittent claudication is an ischemic muscle ache or pain that is precipitated by a consistent level of exercise, resolves within 10 minutes or less with rest, and is reproducible. Angina is the term used to describe chest pain with exertion. Paresthesia is the term used to describe numbness or tingling in the toes or feet. Reactive hyperemia is the term used to describe redness of the foot; if the limb is in a dependent position the term is dependent rubor.

An older adult patient is admitted with acute respiratory distress related to cor pulmonale. Which nursing action is most appropriate during admission of this patient? Perform a comprehensive health history with the patient to review prior respiratory problems. Complete a full physical examination to determine the effect of the respiratory distress on other body functions. Delay any physical assessment of the patient and review with the family the patient's history of respiratory problems. Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress.

Perform a physical assessment of the respiratory system and ask specific questions related to this episode of respiratory distress. Because the patient is having respiratory difficulty, the nurse should ask specific questions about this episode and perform a physical assessment of this system. Further history taking and physical examination of other body systems can proceed when the patient's acute respiratory distress is being managed.

The nurse is preparing to administer a scheduled dose of enoxaparin (Lovenox) 30 mg subcutaneously. What should the nurse do to administer this medication correctly? Remove the air bubble in the prefilled syringe. Aspirate before injection to prevent IV administration. Rub the injection site after administration to enhance absorption. Pinch the skin between the thumb and forefinger before inserting the needle.

Pinch the skin between the thumb and forefinger before inserting the needle. The nurse should gather together or "bunch up" the skin between the thumb and the forefinger before inserting the needle into the subcutaneous tissue. The nurse should not remove the air bubble in the prefilled syringe, aspirate, nor rub the site after injection.

During discharge teaching for an older adult patient with chronic obstructive pulmonary disease (COPD) and pneumonia, which vaccine should the nurse recommend that this patient receive? Pneumococcal Staphylococcus aureus Haemophilus influenzae Bacille-Calmette-Guérin (BCG)

Pneumococcal The pneumococcal vaccine is important for patients with a history of heart or lung disease, recovering from a severe illness, age 65 years or older, or living in a long-term care facility. A Staphylococcus aureus vaccine has been researched but not yet been effective. The Haemophilus influenzae vaccine would not be recommended as adults do not need it unless they are immunocompromised. The BCG vaccine is for infants in parts of the world where tuberculosis is prevalent.

The nurse is caring for a patient with unilateral malignant lung disease. What is the priority nursing action to enhance oxygenation in this patient? Positioning patient on right side Maintaining adequate fluid intake Positioning patient with "good lung" down Performing postural drainage every 4 hours

Positioning patient with "good lung" down Therapeutic positioning identifies the best position for the patient, thus assuring stable oxygenation status. Research indicates that positioning the patient with the unaffected lung (good lung) dependent best promotes oxygenation in patients with unilateral lung disease. For bilateral lung disease, the right lung down has best ventilation and perfusion. Increasing fluid intake and performing postural drainage will facilitate airway clearance, but positioning is most appropriate to enhance oxygenation.

The nurse is caring for a preoperative patient who has an order for vitamin K by subcutaneous injection. The nurse should verify that which laboratory study is abnormal before administering the dose? Hematocrit (Hct) Hemoglobin (Hgb) Prothrombin time (PT) Partial thromboplastin time (PTT)

Prothrombin time (PT) Vitamin K counteracts hypoprothrombinemia and/or reverses the effects of warfarin (Coumadin) and thus decreases the risk of bleeding. High values for either the PT or the international normalized ratio demonstrate the need for this medication.

Assessment of a patient's peripheral IV site reveals that phlebitis has developed over the past several hours. Which intervention should the nurse implement first? Remove the patient's IV catheter. Apply an ice pack to the affected area. Decrease the IV rate to 20 to 30 mL/hr. Incorrect Administer prophylactic anticoagulants.

Remove the patient's IV catheter. The priority intervention for superficial phlebitis is removal of the offending IV catheter. Decreasing the IV rate is insufficient. Anticoagulants are not normally required, and warm, moist heat is often therapeutic.

When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate? Increase water intake. Restrict sodium intake. Increase protein intake. Use calcium supplements.

Restrict sodium intake. The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Protein intake does not affect hypertension. Calcium supplements are not recommended to lower blood pressure.

When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat? Broiled fish Roasted duck Roasted turkey Baked chicken breast

Roasted duck Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall cardiovascular disease risk. The other meats are lower in fat and are therefore acceptable in the diet.

In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage? Serum uric acid of 3.8 mg/dL Serum creatinine of 2.6 mg/dL Serum potassium of 3.5 mEq/L Blood urea nitrogen of 15 mg/dL

Serum creatinine of 2.6 mg/dL The normal serum creatinine level is 0.6 to 1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other laboratory results are within normal limits.

The nurse is caring for an older adult patient who underwent a left total knee arthroplasty. On the third postoperative day, the patient reports shortness of breath, slight chest pain, and that "something is wrong." Temperature is 98.4°F, blood pressure is 130/88 mm Hg, respirations are 36 breaths/min, and oxygen saturation is 91% on room air. What is the priority nursing action? Notify the health care provider. Administer a nitroglycerin tablet sublingually. Conduct a thorough assessment of the chest pain. Sit the patient up in bed as tolerated and apply oxygen.

Sit the patient up in bed as tolerated and apply oxygen. The patient's clinical picture is most likely pulmonary embolus, and the first action the nurse takes should be to assist with the patient's respirations. For this reason, the nurse should sit the patient up as tolerated and apply oxygen before notifying the physician. The nitroglycerin tablet would not be helpful, and the oxygenation status is a bigger problem than the slight chest pain at this time.

A 62-yr-old Hispanic male patient with diabetes mellitus has been diagnosed with peripheral artery disease (PAD). The patient is a smoker with a history of gout. To prevent complications, which factor is priority in patient teaching? Gender Smoking Ethnicity Comorbidities

Smoking Smoking is the most significant factor for this patient. PAD is a marker of advanced systemic atherosclerosis. Therefore, tobacco cessation is essential to reduce PAD progression, CVD events, and mortality. Diabetes mellitus and hyperuricemia are also risk factors. Being male or Hispanic are not risk factors for PAD

After admitting a patient from home to the medical unit with a diagnosis of pneumonia, which physician orders will the nurse verify have been completed before administering a dose of cefuroxime to the patient? Orthostatic blood pressures Sputum culture and sensitivity Pulmonary function evaluation Serum laboratory studies ordered for AM

Sputum culture and sensitivity The nurse should ensure that the sputum for culture and sensitivity was sent to the laboratory before administering the cefuroxime because this is community-acquired pneumonia. It is important that the organisms are correctly identified (by the culture) before the antibiotic takes effect. The test will also determine whether the proper antibiotic has been ordered (sensitivity testing). Although antibiotic administration should not be unduly delayed while waiting for the patient to expectorate sputum, orthostatic blood pressures, pulmonary function evaluation, and serum laboratory tests will not be affected by the administration of antibiotics.

An older adult patient living alone is admitted to the hospital with a diagnosis of pneumococcal pneumonia. Which clinical manifestation, observed by the nurse, indicates that the patient is likely to be hypoxic? Sudden onset of confusion Oral temperature of 102.3oF Coarse crackles in lung bases Clutching chest on inspiration

Sudden onset of confusion Confusion or stupor (related to hypoxia) may be the only clinical manifestation of pneumonia in an older adult patient. An elevated temperature, coarse crackles, and pleuritic chest pain with guarding may occur with pneumonia, but these symptoms do not indicate hypoxia.

When caring for elderly patients with hypertension, which information should the nurse consider when planning care (select all that apply.)? Systolic blood pressure increases with aging. Blood pressures should be maintained near 120/80 mm Hg. White coat syndrome is prevalent in elderly patients. Volume depletion contributes to orthostatic hypotension. Blood pressure drops 1 hour postprandially in many older patients. Older patients will require higher doses of antihypertensive medications.

Systolic blood pressure increases with aging. White coat syndrome is prevalent in elderly patients. Volume depletion contributes to orthostatic hypotension. Blood pressure drops 1 hour postprandially in many older patients. Systolic blood pressure increases with age and patients older than age 60 years should be maintained below 150/90 mm Hg. Older patients have significantly higher blood pressure readings when taken by health care providers (white coat syndrome). Older patients experience orthostatic hypotension related to dehydration, reduced compensatory mechanisms, and medications. One hour after eating, many older patients experience a drop in blood pressure. Lower doses of medications may be needed to control blood pressures in older adults related to decreased absorption rates and excretion ability.

The UAP is taking orthostatic vital signs. In the supine position, the blood pressure (BP) is 130/80 mm Hg, and the heart rate (HR) is 80 beats/min. In the sitting position, the BP is 140/80, and the HR is 90 beats/min. Which action should the nurse instruct the UAP to take next? Repeat BP and HR in this position. Record the BP and HR measurements. Take BP and HR with patient standing. Return the patient to the supine position

Take BP and HR with patient standing. The vital signs taken do not reflect orthostatic changes, so the UAP will continue with the measurements while the patient is standing. There is no need to repeat or delay the readings. The patient does not need to return to the supine positon. When assessing for orthostatic changes, the UAP will take the BP and pulse in the supine position, then place the patient in a sitting position for 1 to 2 minutes and repeat the readings, and then reposition to the standing position for 1 to 2 minutes and repeat the readings. Results consistent with orthostatic changes would have a decrease of 20 mm Hg or more in systolic BP, a decrease of 10 mm Hg or more in diastolic BP, and/or an increase in HR of greater than or equal to 20 beats/min with position changes.

What is a priority nursing intervention in the care of a patient with a diagnosis of chronic venous insufficiency (CVI)? Application of topical antibiotics to venous ulcers Maintaining the patient's legs in a dependent position Administration of oral and/or subcutaneous anticoagulants Teaching the patient the correct use of compression stockings

Teaching the patient the correct use of compression stockings CVI requires conscientious and consistent application of compression stockings. Anticoagulants are not necessarily indicated and antibiotics, if required, are typically oral or IV, not topical. The patient should avoid prolonged positioning with the limb in a dependent position.

The nurse is admitting a 68-yr-old preoperative patient with a suspected abdominal aortic aneurysm (AAA). The medication history reveals that the patient has been taking warfarin (Coumadin) on a daily basis. Based on this history and the patient's admission diagnosis, the nurse should prepare to administer which medication? Vitamin K Cobalamin Heparin sodium Protamine sulfate

Vitamin K Coumadin is a vitamin K antagonist anticoagulant that could cause excessive bleeding during surgery if clotting times are not corrected before surgery. For this reason, vitamin K is given as the antidote for warfarin (Coumadin).

The patient had aortic aneurysm repair 6 hours ago. What priority nursing action will maintain graft patency? Assess output for renal dysfunction. Use IV fluids to maintain adequate BP. Use oral antihypertensives to maintain cardiac output. Maintain a low BP to prevent pressure on surgical site.

Use IV fluids to maintain adequate BP. The priority is to maintain an adequate blood pressure (BP) (determined by the surgeon) to maintain graft patency. A prolonged low BP may result in graft thrombosis, and hypertension may cause undue stress on arterial anastomoses resulting in leakage of blood or rupture at the suture lines, which is when IV antihypertensives may be used. Renal output will be assessed when the aneurysm repair is above the renal arteries to assess graft patency, not maintain it.

10. A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? (Select all that apply.) a) "Avoid drinking fluids just before and during meals." b) "Rest before meals if you have dyspnea." c) "Have about six small meals a day." d) "Eat high-fiber foods to promote gastric emptying." e) "Increase carbohydrate intake for energy."

a) "Avoid drinking fluids just before and during meals." b) "Rest before meals if you have dyspnea." c) "Have about six small meals a day." Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. The client should increase calorie and protein intake to prevent malnourishment. The client should not increase carbohydrate intake as this will increase carbon dioxide production and increase the client's risk of for acidosis.

17. A nurse is assessing a client with peripheral artery disease (PAD). The client states walking five blocks is possible without pain. What question asked next by the nurse will give the best information? a) "Could you walk further than that a few months ago?" b) "Do you walk mostly uphill, downhill, or on flat surfaces?" c) "Have you ever considered swimming instead of walking?" d) "How much pain medication do you take each day?"

a) "Could you walk further than that a few months ago?"

40. A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this client's teaching? (Select all that apply.) a) "Do not walk around barefoot." b) "Soak your feet in a tub each evening." c) "Trim toenails straight across with a nail clipper." d) "Treat any blisters or sores with Epsom salts." e) "Wash your feet every other day."

a) "Do not walk around barefoot." c) "Trim toenails straight across with a nail clipper."

19. A client has peripheral arterial disease (PAD). What statement by the client indicates misunderstanding about self-management activities? a) "I can use a heating pad on my legs if it's set on low." b) "I should not cross my legs when sitting or lying down." c) "I will go out and buy some warm, heavy socks to wear." d) "It's going to be really hard but I will stop smoking."

a) "I can use a heating pad on my legs if it's set on low."

28. A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a) "Maintain tight glycemic control and prevent hyperglycemia." b) "Restrict your fluid intake to no more than 2 liters a day." c) "Prevent hypoglycemia by eating a bedtime snack." d) "Limit your intake of protein to prevent ketoacidosis."

a) "Maintain tight glycemic control and prevent hyperglycemia."

27. A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How should the nurse respond? a) "Your risk of diabetes is higher than the general population, but it may not occur." b) "No genetic risk is associated with the development of type 1 diabetes mellitus." c) "The risk for becoming a diabetic is 50% because of how it is inherited." d) "Female children do not inherit diabetes mellitus, but male children will."

a) "Your risk of diabetes is higher than the general population, but it may not occur."

8. The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." a) 4, 2, 1, 3, 5, 6, 7 b) 3, 4, 1, 2, 5, 7, 6 c) 2, 1, 3, 4, 5, 6, 7 d) 1, 3, 2, 5, 6, 7, 4

a) 4, 2, 1, 3, 5, 6, 7

30. A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? a) Administer 1 mg of intramuscular glucagon. b) Encourage the client to drink orange juice. c) Insert a new intravenous access line. d) Administer 25 mL dextrose 50% (D50) IV push.

a) Administer 1 mg of intramuscular glucagon.

36. A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the client's clinical manifestations have not changed. Which action should the nurse take next? a) Administer another half-cup of orange juice. b) Administer a half-ampule of dextrose 50% intravenously. c) Administer 10 units of regular insulin subcutaneously. d) Administer 1 mg of glucagon intramuscularly.

a) Administer another half-cup of orange juice.

15. A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to what target audience should the nurse provide this service? a) African-American churches b) Asian-American groceries c) High school sports camps d) Women's health clinics

a) African-American churches

12. A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a) Ask the client to drink 2 liters of fluids daily. b) Add humidity to the prescribed oxygen. c) Suction the client every 2 to 3 hours. d) Use a vibrating positive expiratory pressure device. e) Encourage diaphragmatic breathing.

a) Ask the client to drink 2 liters of fluids daily. b) Add humidity to the prescribed oxygen. d) Use a vibrating positive expiratory pressure device. Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client's ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

21. The nurse working in the emergency department knows that which factors are commonly related to aneurysm formation? (Select all that apply.) a) Atherosclerosis b) Down syndrome c) Frequent heartburn d) History of hypertension e) History of smoking

a) Atherosclerosis d) History of hypertension e) History of smoking

44. A client with diabetes has frequent blood glucose readings higher than 300 mg/dL. Which action does the nurse teach the client about self-care? a) Check urine ketones when blood glucose readings are high. b) Increase the insulin dose after two high glucose readings in a row. c) Change the diet to include a 10% increase in protein. d) Work out on the treadmill whenever glucose readings are high.

a) Check urine ketones when blood glucose readings are high.

16. The nurse is caring for four hypertensive clients. Which drug-laboratory value combination should the nurse report immediately to the health care provider? a) Furosemide (Lasix)/potassium: 2.1 mEq/L b) Hydrochlorothiazide (Hydrodiuril)/potassium: 4.2 mEq/L c) Spironolactone (Aldactone)/potassium: 5.1 mEq/L d) Torsemide (Demadex)/sodium: 142 mEq/L

a) Furosemide (Lasix)/potassium: 2.1 mEq/L

3. A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this client's history and clinical manifestations? a) Increased pulmonary pressure creating a higher workload on the right side of the heart b) Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c) Increased number and size of mucus glands producing large amounts of thick mucus d) Left ventricular hypertrophy creating a decrease in cardiac output

a) Increased pulmonary pressure creating a higher workload on the right side of the heart Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history.

31. An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a) Increased rate and depth of respiration b) Extremity tremors followed by seizure activity c) Oral temperature of 102° F (38.9° C) d) Severe orthostatic hypotension

a) Increased rate and depth of respiration

41. A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a) Stroke b) Kidney failure c) Blindness d) Respiratory failure e) Cirrhosis

a) Stroke b) Kidney failure c) Blindness

A plan of care for the patient with COPD could include (select all that apply) a. exercise such as walking. b. high flow rate of O2 administration. c. low-dose chronic oral corticosteroid therapy. d. use of peak flow meter to monitor the progression of COPD. e. breathing exercises such as pursed-lip breathing that focus on exhalation.

a. exercise such as walking. e. breathing exercises such as pursed-lip breathing that focus on exhalation.

29. A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How should the nurse respond? a) "You need to start with multiple injections until you become more proficient at self-injection." b) "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." c) "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d) "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock."

b) "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns."

11. A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.) a) "What color is your sputum?" b) "Do you have any difficulty sleeping?" c) "How long does it take to perform your morning routine?" d) "Do you walk upstairs every day?" e) "Have you lost any weight lately?"

b) "Do you have any difficulty sleeping?" c) "How long does it take to perform your morning routine?" e) "Have you lost any weight lately?" Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.

13. A client has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a) "Do you have trouble affording your medications?" b) "Most people with hypertension do not have symptoms." c) "You are lucky; most people get severe morning headaches." d) "You need to take your medicine or you will get kidney failure."

b) "Most people with hypertension do not have symptoms."

23. A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL?" How should the nurse respond? a) "Glucose is the only fuel used by the body to produce the energy that it needs." b) "Your brain needs a constant supply of glucose because it cannot store it." c) "Without a minimum level of glucose, your body does not make red blood cells." d) "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."

b) "Your brain needs a constant supply of glucose because it cannot store it."

5. A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a) A 46-year-old with a 30-pack-year history of smoking b) A 52-year-old in a tripod position using accessory muscles to breathe c) A 68-year-old who has dependent edema and clubbed fingers d) A 74-year-old with a chronic cough and thick, tenacious secretions

b) A 52-year-old in a tripod position using accessory muscles to breathe The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure. The other clients are not in acute distress.

22. A client with a known abdominal aortic aneurysm reports dizziness and severe abdominal pain. The nurse assesses the client's blood pressure at 82/40 mm Hg. What actions by the nurse are most important? (Select all that apply.) a) Administer pain medication. b) Assess distal pulses every 10 minutes. c) Have the client sign a surgical consent. d) Notify the Rapid Response Team. e) Take vital signs every 10 minutes.

b) Assess distal pulses every 10 minutes. d) Notify the Rapid Response Team. e) Take vital signs every 10 minutes.

45. The nurse has been reviewing options for insulin therapy with several clients. For which client does the nurse choose to recommend the pen-type injector insulin delivery system? a) Older adult client who lives at home alone but has periods of confusion b) Client on an intensive regimen with frequent, small insulin doses c) Client from the low-vision clinic who has trouble seeing the syringe d) "Brittle" client who has frequent episodes of hypoglycemia

b) Client on an intensive regimen with frequent, small insulin doses

39. A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dL Postprandial blood glucose: 200 mg/dL Hemoglobin A1C level: 5.5% How should the nurse interpret these laboratory findings? a) Increased risk for developing ketoacidosis b) Good control of blood glucose c) Increased risk for developing hyperglycemia d) Signs of insulin resistance

b) Good control of blood glucose

48. A client with a history of diabetes mellitus has new onset of microalbuminuria. Which component of the diet must the client reduce? a) Percentage of total calories derived from carbohydrates b) Percentage of total calories derived from proteins c) Percentage of total calories derived from fats d) Total caloric intake

b) Percentage of total calories derived from proteins

35. A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? a) Urine specific gravity of 1.033 b) Presence of protein in the urine c) Elevated capillary blood glucose level d) Presence of ketone bodies in the urine

b) Presence of protein in the urine

49. The nurse is teaching a client with type 2 diabetes about acute complications. Which teaching point by the nurse is most accurate? a) Ketosis is less prevalent among obese adults owing to the protective effects of fat. b) People with type 2 diabetes have normal lipid metabolism, so ketones are not made. c) Insulin produced in type 2 diabetes prevents fat catabolism but not hyperglycemia. d) Oral antidiabetic agents do not promote the breakdown of fat for fuel (lipolysis).

c) Insulin produced in type 2 diabetes prevents fat catabolism but not hyperglycemia.

1. After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching? a) The client lays on his or her side with his or her knees bent. b) The client places his or her hands on his or her abdomen. c) The client lays in a prone position with his or her legs straight. d) The client places his or her hands above his or her head.

b) The client places his or her hands on his or her abdomen. To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

32. A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a) pH 7.38, HCO 22 mEq/L, PCO 38 mm Hg, PO 98 mm Hg b) pH 7.28, HCO 18 mEq/L, PCO 28 mm Hg, PO 98 mm Hg c) pH 7.48, HCO 28 mEq/L, PCO 38 mm Hg, PO 98 mm Hg d) pH 7.32, HCO 22 mEq/L, PCO 58 mm Hg, PO 88 mm Hg

b) pH 7.28, HCO 18 mEq/L, PCO 28 mm Hg, PO 98 mm Hg

The effects of cigarette smoking on the respiratory system include a. hypertrophy of capillaries causing hemoptysis. b. hyperplasia of goblet cells and increased production of mucus. c. increased proliferation of cilia and decreased clearance of mucus. d. proliferation of alveolar macrophages to decrease the risk for infection.

b. hyperplasia of goblet cells and increased production of mucus.

4. A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a) "Do you have a strong support system?" b) "What do you understand about your disease?" c) "Do you experience shortness of breath with basic activities?" d) "What medications are you prescribed to take each day?"

c) "Do you experience shortness of breath with basic activities?" Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse should ask the client if shortness of breath is interfering with basic activities. Although the nurse should know about the client's support systems, current knowledge, and medications, these questions do not address the client's appearance.

6. The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? a) "I plan to wear my oxygen when I exercise and feel short of breath." b) "I will use my portable oxygen when grilling burgers in the backyard." c) "I plan to use cotton balls to cushion the oxygen tubing on my ears." d) "I will only smoke while I am wearing my oxygen via nasal cannula."

c) "I plan to use cotton balls to cushion the oxygen tubing on my ears." Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling and smoking increases the risk for fire.

20. Which statements by the client indicate good understanding of foot care in peripheral vascular disease? (Select all that apply.) a) "A good abrasive pumice stone will keep my feet soft." b) "I'll always wear shoes if I can buy cheap flip-flops." c) "I will keep my feet dry, especially between the toes." d) "Lotion is important to keep my feet smooth and soft." e) "Washing my feet in room-temperature water is best."

c) "I will keep my feet dry, especially between the toes." d) "Lotion is important to keep my feet smooth and soft." e) "Washing my feet in room-temperature water is best."

2. A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a) "There are a variety of support groups for people who have COPD." b) "I will ask your provider to prescribe you with an antianxiety agent." c) "Share any thoughts and feelings that cause you to limit social activities." d) "Friends can be a good support system for clients with chronic disorders."

c) "Share any thoughts and feelings that cause you to limit social activities." Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

26. A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a) Document the finding in the client's chart. b) Assess tactile sensation in the client's hands. c) Examine the client's feet for signs of injury. d) Notify the healthcare provider.

c) Examine the client's feet for signs of injury.

38. A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a) Serum potassium level has increased. b) Blood osmolarity has decreased. c) Glasgow Coma Scale score is unchanged. d) Urine remains negative for ketone bodies.

c) Glasgow Coma Scale score is unchanged.

25. After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a) "At my age, I should continue seeing the ophthalmologist as I usually do." b) "I will see the eye doctor when I have a vision problem and yearly after age 40." c) "My vision will change quickly. I should see the ophthalmologist twice a year." d) "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

d) "Diabetes can cause blindness, so I should see the ophthalmologist yearly."

34. A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this client's teaching to prevent injury? a) "Examine your feet using a mirror every day." b) "Rotate your insulin injection sites every week." c) "Check your blood glucose level before each meal." d) "Use a bath thermometer to test the water temperature."

d) "Use a bath thermometer to test the water temperature." Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer. Not A. Examining the feet daily does not prevent injury, although daily foot examinations are important to find problems so they can be addressed. Rotating insulin and checking blood glucose levels will not prevent injury.

7. A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, "What does this mean?" How should the nurse respond? a) "Your children will be at high risk for the development of chronic obstructive pulmonary disease." b) "I will contact a genetic counselor to discuss your condition." c) "This is a recessive gene and should have no impact on your health." d) "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke."

d) "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent chronic obstructive pulmonary disease (COPD) unless the client smokes. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partner's AAT levels. Contacting a genetic counselor may be helpful but does not address the client's current question.

33. A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a) Administration of oxygen via face mask b) Intravenous administration of 10% glucose c) Implementation of seizure precautions d) Administration of intravenous insulin

d) Administration of intravenous insulin

9. A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3- = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? a) Administer a short-acting beta2 agonist inhaler. b) Document the findings as normal for a client with COPD. c) Teach the client diaphragmatic breathing techniques. d) Initiate oxygenation therapy to increase saturation to 92%.

d) Initiate oxygenation therapy to increase saturation to 92%. Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the client's hypoxia, which is the priority.