Acute Test 3

You are caring for a diabetic patient who is developing DKA. Which task delegation is most important? 1 ask the unit clerk to page the physician to come to the unit 2 ask the LPN to administer IV push insulin 3 as the UAP to hang a new bag of NS 4 ask the UAP to get the patient a cup of orange juice

1 ask the unit clerk to page the physician to come to the unit

An LPN is to administer rapid-acting insulin (Lispro) to a patient with type 1 diabetes. What essential information would you be sure to tell the LPN? 1 Give the insulin after the patients food tray has been delivered and the patient is ready to eat 2 Only give this insulin if the patient's finger stick glucose reading is above 200 mg/dL 3 this insulin mimics the basal glucose control of the pancreas 4 rapid acting insulin is the only insulin that can be given subcutaneously or IV

1 Give the insulin after the patients food tray has been delivered and the patient is ready to eat

The UAP reports to you that a patient with type 1 diabetes has a question about exercise. What important points would you be sure to teach this patient? (select all that apply) 1 exercise guidelines are based on blood glucose and urine ketone levels 2 due sure to test your blood glucose only after exercising 3 you can exercise vigorously if you blood glucose is between 100 and 250 mg/dL 4 exercise will help resolve the presence of ketones in your urine 5 a 5-10 min warm up and cool down period should be included in your exercise

1 exercise guidelines are based on blood glucose and urine ketone levels 3 you can exercise vigorously if you blood glucose is between 100 and 250 mg/dL 5 a 5-10 min warm up and cool down period should be included in your exercise

You are caring for an 81 y/o with type 2 diabetes, hypertension and peripheral vascular disease. Which admission assessment findings increase the patient's risk for development of hyperglycemic-hyperosomolar syndrome (HHS)? (select all that apply) 1 hydrochlorothiazide (HCTZ) prescribed to control her diabetes 2 weight gain of 6 lbs over the past month 3 avoids consuming liquids in the evening 4 BP of 168/94 mm Hg 5 urine output of 50-75 mL/hr

1 hydrochlorothiazide (HCTZ) prescribed to control her diabetes 3 avoids consuming liquids in the evening

You are providing care for a patient who underwent thyroidectomy 2 days ago. Which laboratory value requires close monitoring by a nurse? 1. Calcium level 2. Sodium level 3. Potassium level 4. WBC count

1. Calcium level

When providing care for a patient with Addison disease, you should be alert for which laboratory value change? 1. Decreased hematocrit 2. Increased sodium level 3. Decreased potassium level 4. Decreased calcium level

1. Decreased hematocrit

A female patient is admitted with a diagnosis of primary hypo function of the adrenal glands. Which assessment finding supports this diagnosis? 1. Patchy areas of pigment loss over the face 2. Decreased muscle strength 3. Greatly increased urine output 4. Scalp alopecia

1. Patchy areas of pigment loss over the face

You are preparing a care plan for a patient with Cushing disease. Which nursing diagnosis would you be sure to include? (select all that apply) 1. Risk for injury related to the potential for bruising 2. Disturbed body image 3. Imbalanced nutrition: less than body requirements 4. Risk for injury related to the potential for hypertension 5. Risk for infection

1. Risk for injury related to the potential for bruising 2. Disturbed body image 4. Risk for injury related to the potential for hypertension 5. Risk for infection

You are caring for a patient with hyperthyroidism who had a partial thyroidectomy yesterday. Which change in assessment would you report to the health care provider immediately? 1. Temp elevation to 100.2 2. HR increase from 64 BPM to 76 BPM 3. RR decrease from 26 to 16 4. Pulse ox reading of 92%

1. Temp elevation to 100.2

a patient is hospitalized with adrenocorticol insufficiency. Which nursing activity should you delegate to the UAP? 1. reminding the patient to change positions slowly 2. assessing the patients for muscle weakness 3. teaching the patient how to collect a 24-hour urine sample 4. revising the patients nursing plan of care

1. reminding the patient to change positions slowly

Which healthcare provider orders for the patient with Addisons disease should you delegate to the experienced UAP? (select all that apply) 1. Weigh the patient every morning 2. Obtain fingerstick glucose before each meal and at bedtime 3. Check vital signs every 2 hours 4. Monitor for cardiac dysrhythmias 5. Administer oral prednisone 10 mg every morning 6. Record intake and output

1. Weigh the patient every morning 2. Check vital signs every 2 hours 3. Check vital signs every 2 hours 6. Record intake and output

the plan of care for a diabetic patient includes all of these interventions. Which intervention should you delegate to the UAP? 1. checking to make sure the bath water isn't too hot 2. discussing community resources for diabetic outpatient care 3. teaching the patient to perform daily foot inspection 4. assessing the patient's technique for drawing insulin into a syringe

1. checking to make sure the bath water isn't too hot

a nursing diagnosis for a patient with newly-diagnosed diabetes is risk for injury related to sensory alterations. which key points should you include in the teaching plan for this patient? 1. clean and inspect your feet daily 2. be sure your shoes fit properly 3. nylon socks are best to prevent friction on your toes from shoes 4. only a podiatrist should trim your toe nails 5. report any nonhealing skin breaks to your healthcare provider

1. clean and inspect your feet daily 2. be sure your shoes fit properly 5. report any nonhealing skin breaks to your healthcare provider

a patient with adrenal insufficiency is to be discharged and will take prednisone (Deltasone) 10 mg orally each day. Which instruction would you be sure to teach the patient? 1. excessive which gain or swelling should be reported to the physician 2. changing positions rapidly may cause hypotension 3. a diet with foods low in sodium may be beneficial 4. signs of hypoglycemia may occur while taking this drug

1. excessive which gain or swelling should be reported to the physician

a 58 y/o with type 2 diabetes was admitted to your unit with the diagnosis of COPD exacerbation. When you prepare a care plan for this patient, what would you be sure to include? 1. fingerstick blood glucose checks before meals and at bedtime 2. sliding-scale insulin dosing as ordered 3. bedrest until the COPD exacerbation is resolved 4. teaching about the atkins diet for weight loss 5. demonstration for the components of foot care

1. fingerstick blood glucose checks before meals and at bedtime 2. sliding-scale insulin dosing as ordered 5. demonstration for the components of foot care

You are serving as a preceptor to a nurse who has recently graduated and passed the RN licensure examination. The new nurse has only been on the unit for 2 days. Which patient should you assign to the new nurse? 1 68 y/o with diabetes who is showing signs of hyperglycemia 2 58 y/o with diabetes who has cellulitis of the L ankle 3 49 y/o with diabetes who has just returned from the post-anesthesia care unit after a BKA 4 72 y/o with diabetes with DKA who is receiving IV insulin

2 58 y/o with diabetes who has cellulitis of the L ankle

Which actions can the school nurse delegate to the UAP who is working with a 7 y/o with type 1 diabetes in an elementary school? (select all that apply) 1 obtaining information about the child's usual insulin use from the parents 2 administering oral glucose tablets when blood glucose level falls below 60 mg/dL 3 teaching the child about what foods have high carb levels 4 obtaining blood glucose readings using the child's blood glucose monitor 5 reminding the child to have a snack after the physical education class

2 administering oral glucose tablets when blood glucose level falls below 60 mg/dL 4 obtaining blood glucose readings using the child's blood glucose monitor 5 reminding the child to have a snack after the physical education class

A patient with diabetes has hot, dry skin; rapid and deep respirations and a fruity order to his breath. As charge nurse, you observe a newly graduated RN performing all the following patient tasks. Which one requires that you intervene immediately? 1 checking the patient's finger stick glucose level 2 encouraging the patient to drink orange juice 3 checking the patient's order for sliding-scale insulin dosing 4 assessing the patient's vital signs every 15 min

2 encouraging the patient to drink orange juice

In the emergency department during initial assessment of a newly-admitted patient with diabetes, the nurse discovers all of these findings. Which findings should be reported to the health care provider immediately 1 hammer toe of the left second metatarsophalangeal joint 2 rapid respiratory rate with deep inspirations 3 numbness and tingling bilaterally on the feet and hands 4 decreased sensitivity and swelling of the abdomen

2 rapid respiratory rate with deep inspirations

You are the preceptor for a senior nursing student who will teach a diabetic patient about self-care during sick days. For which statement by the student must you intervene? 1 when you are sick, be sure to monitor your blood glucose every 4 hours 2 test your urine for ketones whenever your blood glucose level is less than 240 mg/dL 3 to prevent dehydration, drink 8 oz of sugar-free liquid every hour while you are awake 4 continue to eat your meals and snacks at the usual times

2 test your urine for ketones whenever your blood glucose level is less than 240 mg/dL

You admit a patient whose assessment reveals prominent brow ridge, large hands and feet and large lips and nose. Which pituitary hormone do you suspect is elevated? 1. Thyroid-stimulating hormone 2. Growth hormone 3. Adrenocorticotropic hormone 4. Vasopressin antidiuretic hormone

2. Growth hormone

Which patients should you, as the charge nurse, assign to the care of an LPN/LVN, under the supervision of the RN team leader? 1. 51 y/o who has just undergone bilateral adrenalectomy 2. 83 y/o with type 2 diabetes and chronic obstructive pulmonary disease 3. 38 y/o with MI preparing for discharge 4. 72 y/o with mental status Changes admitted from a long-term care facility

2. 83 y/o with type 2 diabetes and chronic obstructive pulmonary disease

Two UAPs are assisting a patient with Cushing disease to move up in bed. Which action by the UAPs requires your immediate intervention 1. Positioning themselves on opposite sides of the patients bed 2. Grasping under the patients arm to pull him up in bed 3. Lowering the side rails of the patient's bed before moving him 4. Removing the pillow before moving the patient up in bed

2. Grasping under the patients arm to pull him up in bed

The LPN/LVN asks you why the patient with Cushing disease has bruising and petechiae across her abdomen. What is your best response? 1. Patients with Cushing disease often have bleeding disorders 2. Patients with Cushing disease have very fragile capillaries 3. Please ask the patient if she slipped or fell during the night 4. Thin and delicate skin can result in development of bruising

2. Patients with Cushing disease have very fragile capillaries

as the shift begins, you are assigned to care for the following patients. Which patient should you assess first? 1. 38 year old with graves disease and a HR of 94 BPM 2. 63 y/o with type 2 diabetes and fingerstick glucose level of 137 3. 58 y/o with hypothyroidism and a HR of 48 BPM 4. 49 y/o with cushing's disease and dependent edema rated as 1+

3. 58 y/o with hypothyroidism and a HR of 48 BPM

for a patient with hyperthyroidism, which task will you delegate to an experienced UAP? 1. instructing the patient to report any occurrence of palpations, dyspnea, vertigo or chest pain 2. monitoring the apical pulse, blood pressure, and temp every 4 hours 3. drawing blood to measure levels of thyroid-stimulating hormone, triiodothyrodine and thyroxine 4. teaching the patient about side effects of the drug propylthiouracil

2. monitoring the apical pulse, blood pressure, and temp every 4 hours

for the patient with pheochromocytoma, which physical assessment technique should you instruct an LPN/LVN to avoid? 1. listening for abdominal bowel sounds in all four quadrants 2. palpating the abdomen in all four quadrants 3. checking the blood pressure every hour 4. assessing the mucous membrane for hydration status

2. palpating the abdomen in all four quadrants

A patient has a newly-diagnosed type 2 diabetes. Which action should you assign to an LPN instead of UAP? 1 measuring the patient's vital signs every shift 2 checking the patient's glucose level before each meal 3 administering SC insulin on a sliding scale as needed 4 assisting the patient with morning care

3 administering SC insulin on a sliding scale as needed

24. The patient with type 2 diabetes is NPO for a cardiac Cath. An LPN who is administering medications to this patient asks you whether the patient should receive his ordered repaglinide (Prandin). What is your best response? 1 yes, because this drug will increase the patients insulin secretion and prevent hyperglycemia 2 no because this drugmay cause the patient to experience GI symptoms such as nausea 3 no because this drug should be given 1-30 min before meals and the patient is NPO 4 yes because this drug should be taken 3 times per day whether he eats or not

3 no because this drug should be given 1-30 min before meals and the patient is NPO

You are caring for the following patients with endocrine disorders. Which one must you assess first? 1. A 21 y/o with diabetes insipidus whose urine output overnight was 2000 mL 2. 55 y/o with syndrome of inappropriate antidiuretic hormone secretion (SIADH) who is demanding that the UAP refill his water pitcher 3. 65 y/o with Addisons disease whose morning potassium level is 6.2 mEq/L 4. A 48 y/o with Cushing disease with a weight gain of 1/5 lbs over the past 4 days

3. 65 y/o with Addisons disease whose morning potassium level is 6.2 mEq/L

The patient with hyperthyroidism who is not a candidate for surgery asks you why she is receiving IV normal saline and IV furosemide. What is your best response? 1. This therapy is to protect your kidney function 2. You are receiving these therapies to prevent edema formation 3. Diuretic and hydration therapies are used to reduce your serum calcium 4. These therapies may help to improve your candidacy for surgery

3. Diuretic and hydration therapies are used to reduce your serum calcium

An LPN/LVN's assessment of two diabetic patients reveals all of these findings. Which would you instruct the LPN/LVN to report immediately? 1. Fingerstick glucose reading of 185 mg/dL 2. Numbness and tingling in both feet 3. Profuse perspiration 4. Bunion on the left great toe

3. Profuse perspiration

a patient is admitted to the medical unit with possible graves disease (hyperthyroidism). Which assessment finding supports this diagnosis? 1. periorbital edema 2. bradycardia 3. exophthalmos 4. hoarse voice

3. exophthalmos

you are preparing to review a teaching plan for a patient with type 2 DM. To determine the patient's level of compliance with his prescribed diabetic regimen, which value would you be sure to review? 1. fasting glucose level 2. oral glucose tolerance test results 3. glycosylated hemoglobin (HgbA1c) level 4. reminding the patient to check glucose level before each meal

3. glycosylated hemoglobin (HgbA1c) level

The experienced UAP has been delegated to take vitals and check glucose on a diabetic patient who is postoperative. Which vital sign change would you instruct the UAP to report immediately? 1 BP increase from 132/80 to 138/84 2 temp increase from 98.4 to 99 F 3 RR increase from 18 to 22 4 glucose increase from 190- 236 mg/dL

4 glucose increase from 190- 236 mg/dL

While working in the diabetes clinic, you obtain this information about an 8 y/o with type 1 diabetes. Which finding is most important to address when planning child and parent education? 1 most recent hemoglobin A1c level of 7.8% 2 many questions about diet choices from the parents 3 Childs participation in soccer practice after school two days per week 4 morning preprandial glucose range of 55-70 mg/dL

4 morning preprandial glucose range of 55-70 mg/dL

A patient with type 1 diabetes reports feeling dizzy. What should the nurse do first? 1 check the patients BP 2 give the patient some OJ 3 give the patient's morning dose of insulin 4 use a glucometer to check the patient's glucose level

4 use a glucometer to check the patient's glucose level

Your are instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would you be sure include when instructing the student about thyroid palpation? 1. Always stand to the side of the patient 2. Instruct the patient not to swallow 3. Palpate using one hand than the other 4. Always palpate the thyroid gland gently

4. Always palpate the thyroid gland gently

13. A 24 y/o patient with diabetes insipidius makes all of these statements when you are preparing the patient for discharge from the hospital. Which statement indicates to you that the patient needs addition teaching? 1. I will drink fluids equal to the amount of my urine 2. I will weigh myself everyday using the same scale 3. I will wear my medical alert bracelet at all times 4. I will gradually wean myself off the vasopressin

4. I will gradually wean myself off the vasopressin

assessment findings for a patient with Cushing disease include all of the following. For which finding would you notify the physician immediately? 1. purple striae present on the abdomen and the thighs 2. weight gain of 1 lb since the previous day 3. dependent edema rated as 1+ in the ankles and calves 4. crackles bilaterally in the lower lobes of the lungs

4. crackles bilaterally in the lower lobes of the lungs

a patient with pheochromocytoma underwent surgery to remove his adrenal glands. Which nursing intervention should you delegate to the UAP? 1. revising the nursing care plan to include strategies to provide a calm and restful environment postoperatively 2. instructing the patient to avoid smoking and drinking caffeine-containing beverages 3. assessing the patient's skin and mucous membranes for signs of adequate hydration 4. monitoring lying and standing BP every 4 hours with a cuff placed on the same arm

4. monitoring lying and standing BP every 4 hours with a cuff placed on the same arm

a patient has newly diagnosed type 2 diabetes. Which task should you delegate to your UAP? 1. arranging a consult with the dietitian 2. assessing the patient's insulin injection technique 3. teaching the patient to use a glucometer to monitor glucose at home 4. reminding the patient to check glucose level before each meal

4. reminding the patient to check glucose level before each meal

a UAP tells you that, while assisting with morning care of a postoperative patient with type 2 diabetes who has been given insulin, the patient aesked if she will always need to take the insulin now. What is your priority for teaching the patient? 1. explain to the patient that she is now considered to have type 1 diabetes 2. tell the patient to monitor fingerstick glucose levels every 4 hours after discharge 3. teach the patient that a person with type 2 diabetes does not always need insulin 4. talk with the patient about the relationship between illness and glucose levels

4. talk with the patient about the relationship between illness and glucose levels

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? a) Dehydration. b) Polyphagia. c) Hyperglycemia. d) Bradycardia.

A

Management of a BUN of 71 and a creatinine of 2.7 in a client with diabetic ketoacidosis (DKA) is correctly accomplished with: a) Rehydration. b) Fluid restriction. c) Dialysis. d) Bladder catheterization.

A

A client with diabetes insipidus is receiving vasopressin. Which sign indicates that the drug is having the intended effect? a) Lower blood pressure b) Concentration of the urine c) Normal insulin levels d) Improved glucose metabolism.

B

A client with diabetic ketoacidosis has been treated with an insulin drip for the past 3 hours. Which imbalance is the client at greatest risk for? a) Hypovolemia. b) Hypokalemia. c) Hyponatremia. d) Hypoglycemia

B

A nurse is assessing a client who has hypoglycemia. Which of the following findings should the nurse expect? a) Fruity breath odor b) Diaphoresis c) Ketones in the urine d) Polyuria

B

A nurse is caring for a client who has diabetes mellitus and is shaky and weak. Which of the following actions should the nurse take? a) Provide subcutaneous insulin for the client. b) Offer the client 120 ml (4 oz) of fruit juice. c) Give the client IV potassium. d) Administer IV sodium bicarbonate.

B

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

Following a thyroidectomy, a nurse assesses for complications related to damage or removal of the parathyroid. The nurse should assess for: a) Hypertension. b) Numbness and tingling around the mouth. c) Polyuria. d) Muscle weakness.

B

The nurse is completing a health assessment of a 42-year old female with suspected Graves' disease. When conducting a focused assessment, what should the nurse assess for? a) Anorexia b) Tachycardia c) Weight gain d) Cold skin

B

A 34-year-old female is diagnosed with hypothyroidism. What in formation should the nurse obtain from conducting a focused assessment. (select all that apply) a) Rapid pulse b) Decreased energy and fatigue c) Weight gain of 10lbs d) Hair with hair loss and dry skin e) Constipation

B, C, D, E

A client is to receive glargine insulin in addition to a dose of aspart. When the nurse checks the blood glucose level it is greater than 200 mg/dL. How should the nurse administer the insulins? a) Put air into the glargine insulin vial and then air into the aspart insulin vial and draw up the correct dose of aspart insulin first. b) Roll the glargine insulin vial, and then roll the aspart insulin vial. Draw up the longest acting glargine insulin first. c) Shake both vials of insulin before drawing up each dose in separate insulin syringes. d) Put air into the glargine insulin vial and draw up the correct dose in an insulin syringe, then with a different insulin syringe, put air into the apart vial, and draw up the correct dose.

D

A client with diabetes has a blood sugar of 300 ml/dL and Na+ of 133. What nursing intervention is indicated to manage the sodium with this client? a) Pad the side rails to protect from injury during a possible seizure. b) Notify dietary department to send salt tablets. c) Encourage the client to drink water. d) Monitor Na+ return to normal with lowering of blood sugar

D

In the care of a patient with type 2 diabetes, which actions can you delegate to a UAP? (select all that apply) ] 1 providing the patient with extra packets of artificial sweetener for coffee 2 assessing how well the patient's shoes fit 3 recording the liquid intake from the patient's breakfast tray 4 teaching the patient what to do if dizziness or lightheadedness occurs 5 checking and recording the patient's blood pressure

1 providing the patient with extra packets of artificial sweetener for coffee 3 recording the liquid intake from the patient's breakfast tray 5 checking and recording the patient's blood pressure

You are caring for a diabetic patient admitted with hypoglycemia that occurred at home. Which teaching points for treatment of hypoglycemia at home would you include in a Teaching plan for the patient and family before discharge? (select all that apply) 1 signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache and blood glucose less than 60 mg/dL 2 treat hypoglycemia with 4-8 g of carbs such as glucose tablets in 1/4 cup of fruit juice 3 retest blood glucose in 30 min 4 repeat the carb treatment if the symptoms do no resolve 5 eat a small snack of carbs and protein if the next meal is more than an hour away

1 signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache and blood glucose less than 60 mg/dL 4 repeat the carb treatment if the symptoms do no resolve 5 eat a small snack of carbs and protein if the next meal is more than an hour away

You are orienting a new graduate nurse who is providing diabetes education for a patient about insulin injection. For which teaching statement by the new nurse must you intervene? 1 to prevent lipohypertrophy, be sure to rotate injection sites from the abdomen to the thighs 2 to correctly inject the insulin, lightly grasp a fold of skin and inject at a 90 degree angle 3 always draw your regular insulin into the syringe first before your NPH insulin 4 avoid injecting insulin into scarred sites because those areas slow the absorption rate of insulin

1 to prevent lipohypertrophy, be sure to rotate injection sites from the abdomen to the thighs

Which actions should you delegate to the LPN/LVN for the care of a patient with hypothyroidism? (select all that apply) 1. Assessing and recording the rate and depth of respirations 2. Osculating lung sounds every 4 hours 3. Creating an individualized nursing care plan for the patient 4. Administering sedation medication every 6 hours 5. Checking blood pressure, HR, and RR every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort

1. Assessing and recording the rate and depth of respirations 2. Osculating lung sounds every 4 hours 6. Reminding the patient to report any episodes of chest pain or discomfort

you are caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which post-operative finding requires immediate intervention? 1. presence of glucose in nasal drainage 2. presence of nasal packing in the nares 3. urine output of 40-50 mL per hour 4. patient reports thirst

1. presence of glucose in nasal drainage

which change in vital signs would you instruct the UAP to report immediately for a patient with hyperthyroidism? 1. rapid heart rate 2. decreased systolic blood pressure 3. increased respiratory rate 4. decreased oral temperature

1. rapid HR

A nurse should assess for hypercalcemia by checking a client for: a) Chvostek's sign b) Trousseau's sign c) Deep tendon reflex d) Babinski reflex

C

While you are performing an admission assessment on a patient with type 2 diabetes, he tells you that he routinely drinks 3 beer/day. What is your priority follow up question at this time? 1 do you have any days when you don't drink? 2 when during the day do you drink your beers? 3 do you drink any other forms of alcohol? 4 have you ever had a lipid profile completed?

2 when during the day do you drink your beers?

Which is the most common treatment for a client in Addisonian crisis? a) IV normal saline and glucocorticoids. b) IV lactated Ringer's and packed cells c) IV 5% dextrose in normal saline and dopamine. d) IV total parenteral nutrition (TPN) and insulin coverage.

A

Which aspect of care is most important for a client with diabetic neuropathy? a) Teach the client to inspect the feet using a mirror. b) Teach the client to wash feet, then pat dry. c) Have client moisturize feet with lotion to prevent dryness. d) Teach the client to cut toenails with a straight across

A-only since the question is asking specifically about diabetic neuropathy However, all answers would be correct when talking about diabetic foot care

A client with type 2 insulin-requiring diabetes has the flu with nausea, body aches and lack of appetite. The client's blood sugar is 180mg/mL. The vital signs are temp: 101; HR 88bpm; and RR 20 breaths/min. What should the nurse instruct the client to do? (select all that apply) a) Stop taking insulin b) Checking blood sugar every 4 hours c) Drink 240 mL fluid every hour d) Check urine for Ketones e) Take two 325mg aspirin

B, C

A 70-year-old male is admitted to the ER with altered mental status. His family reports the client has gained over 10 lbs and has not been able to urinate or eat in the past week. Upon arrival the client's HR is 115, BP 180/92, and serum NA+ is 90. Which of the following conditions is the client likely presenting with? a) Addison's disease b) Diabetes insipidus c) Syndrome of inappropriate diuretic hormone d) Fluid volume deficit

C

A client is admitted with diabetic ketoacidosis (DKA). Five months ago, the hemoglobin A1c (HgbA1c) was 9.4%; currently it is 10.3%. Based on this information, a nurse should: a) Record this expected finding. b) Recheck the HgbA1c after the DKA is resolved. c) Provide diabetic teaching. d) Ask the physician about longer-acting insulin.

C

A client with hyperthyroidism is to have a thyroidectomy. The health care provider has prescribed propranolol. In reviewing the client's history, the nurse notes that the client has asthma. What should the nurse do next? a) Take the client's pulse and withhold the propranolol if the pulse is less than 100 bpm. b) Count the client's respirations and withhold the propranolol if the respirations are less than 20 breaths per minute c) Contact the provider and discuss the prescription for propranolol because of the client's history of having asthma d) Instruct the client to make position changes slowly.

C

A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective? a) A decrease in blood sugar b) A decrease in blood pressure c) A decrease in urinary output d) A decrease in specific gravity

C

Which nursing intervention should a nurse complete first for a client experiencing Addisonian crisis? a) Maintain a quiet, non-stressful environment. b) Take measures to avoid exertion by the client. c) Administer hormone replacement as prescribed. d) IV administration of fluid, glucose, and electrolytes.

D