adult med sure assessment 2
A nurse is teaching a client who has type 1 diabetes mellitus about hypoglycemia . Which of the following statements by the client indicates an understanding of the teaching ? "exercise reduces the risk for hypoglycemia" "I can skip my insulin when I don't eat" "I can drink 4 ounces of soda if my blood sugar is low" "diabetic pills don't cause hypoglycemia; only insulin does"
"I can drink 4 ounces of soda if my blood sugar is low" The client can correct any development of hypoglycemia with a quick intake of a substance that is high in glucose. The client should have 15 g carbohydrates on hand to treat hypoglycemic episodes, such as six to 10 hard candies or 4 oz of regular, not diet, soda or juice. The nurse also should teach the client that exercise can cause hypoglycemia and to consult with the provider prior to any change in dietary regimen so that the provider can adjust the insulin prescription.
A nurse at a provide office is interviewing a client who has multiple sclerosis and has been taking dantrolone for several months . Which of the following client statements should the nurse identify as an indication that the medication is effective ? "I don't have muscle spasms as frequently" "I haven't gotten any colds, eve though it is flu season" "I feel like my nerve pain has improved" "it is easier to urinate now"
"I don't have muscle spasms as frequently" The nurse should identify that dantrolene relaxes the skeletal muscles. It is prescribed to treat muscle spasms for clients who have multiple sclerosis.
A nurse is providing teaching to a client who is scheduled for an electroencephalogram ( EEG ) . Which of the following statements by the client indicates an understanding of the teaching ? "I should not wash my hair prior to the procedure" "I will receive a sedative 1 hr before the procedure" "I should avoid eating prior to the procedure" "I will be exposed to flashed of light during the procedure"
"I will be exposed to flashed of light during the procedure" The nurse should tell the client that flashes of light or pictures are often used by the technician during the procedure to assess the client's response to stimuli and to determine the potential for seizures.
A nurse is providing discharge instructions to a client who has GERD . Which of the following statements by the client demonstrates an understanding of the teaching ? "I should take my meds with OJ" "a bedtime snack will prevent heartburn" "I will lie down after meals" "I will limit activities that require bending at the waist"
"I will limit activities that require bending at the waist" The nurse should instruct the client to limit wearing tight clothing, heavy lifting, and working in a bent-over position because these activities increase intra-abdominal pressure, which leads to episodes of reflux. GERD is caused by inappropriate relaxation of the lower esophageal sphincter. Increased intra-abdominal pressure can be triggered by bending at the waist.
A nurse is assessing a client who has a permanent spinal cord injury and is scheduled for discharge . Which of the following client statements indicates that the client is coping effectively ? "I would like to play wheelchair basketball. when I get stringer, I think I'll look for a league" "I'm glad I'll only be in this wheelchair temporarily. I can't wait to get back to running" "im so upset that this happened to me. what did I do to deserve this, and why am I not getting better?" "I feel like ill never be able to do anything that I want again. all I am is a burden to my family"
"I would like to play wheelchair basketball. when I get stringer, I think I'll look for a league" This statement shows that the client has accepted the disability and the need to adapt abilities. This also shows that the client is looking towards the future and setting realistic goals.
a rn is providing teaching to a client who was newly dx w nephrotic syndrome. which of the following statements should indicated to the rn that the client understands the teaching? "i can expect swelling in my hands and on my face" "the amount of protein in my blood os high" "I might have some pain and gas in my stomach from this condition" "I will use a soft-bristle toothbrush so my gums don't bleed"
"i can expect swelling in my hands and on my face" Nephrotic syndrome is a disorder in which the permeability of the glomeruli increases, thus facilitating the excretion of large amounts of protein. Manifestations include edema, especially of the face and in dependent areas, and impairment of kidney function.
A nurse is caring for a client who has burn injuries covering their upper body and is concerned about their altered appearance . Which of the following statements should the nurse make ? "it is okay to not want to touch the burned areas of your body" "cosmetic sx should be performed within the next year to be effective" "reconstructive sx can completely restore your previous appearance" "it could be helpful for you to attend a support group for people who have burn injuries"
"it could be helpful for you to attend a support group for people who have burn injuries" The nurse should encourage the client to attend a support group for clients who have burn injuries. Support groups, informational sessions, and counseling are interventions that can help the client with the acceptance of their appearance. The nurse should assist the client with finding a support group, if desired.
A nurse is caring for a client who is to undergo a liver biopsy . Which of the following instructions should the nurse provide to the client following the procedure? "lie on your left side" "lie on your right side" "increase your fluid intake" "decrease your fluid intake"
"lie on your right side" Following a liver biopsy, the nurse should instruct the client to lie on the affected side for hemostasis to occur. The liver sits just under the rib cage on the right side of the abdomen.
A nurse is providing discharge teaching to a client who is starting to take carbidopa / levodopa to treat Parkinson's disease . Which of the following instructions should the nurse include in the teaching ? "this med can cause your urine to turn a dark color" "expect immediate relief after taking this med" "take the med with a high-protein food" "skip a dose of the med if you experience dizziness"
"this medication can cause your urine to turn a dark color" The nurse should instruct the client that a harmless effect of carbidopa/levodopa is dark-colored urine, saliva, and sweat.
A nurse is teaching a client about fecal occult blood testing ( FOBT ) for the screening of colorectal cancer . Which of the following statements should the nurse include in the teaching ? "your provider will use stool from your digital rectal exam to perform the test" "you provider will rx a stimulant laxative prior to the procedure to evacuate the bowel" "you should begin annual fecal occult blood testing for colorectal cancer scream at 40 years old" "you should avoid taking corticosteroids prior to testing"
"you should avoid taking corticosteroids prior to testing" The nurse should instruct the client to avoid taking corticosteroids, anti-inflammatory medications, and vitamin C prior to testing to prevent false positive results.
a rn is providing teaching to a client who is schedule for electromyography (EMG). the rn should incl which of the following info in the teaching? "you will receive a fixed dose of radioisotope 2 hours before the procedure?" "momentary flushing will occur at the beginning of the procedure" "you should inform your provider if you are claustrophobic" "you should expect insertion of small needle electrodes into the muscles"
"you should expect insertion of small needle electrodes into the muscles" The nurse should inform the client that the provider will insert a small-gauge needle into the muscles to identify muscle weakness and evaluate local nerve responses.
A nurse is teaching client who has hypertension about dietary modifications to help control blood pressure . Which of the following food choices should the nurse recommend as the client to include in their diet ? 1 packet of reconstituted dry onion soup 3 oz of lean cured ham 3 oz of chicken breast 1/2 cup of canned baked beans
3 oz of chicken breast A low-sodium diet is recommended for a client who has hypertension. Therefore, the nurse should determine that 3 oz of chicken breast is the best food choice to recommend because it contains 30 to 90 mg of sodium.
A nurse is teaching a client about using a continuous positive airway pressure ( CPAP ) device to treat obstructive sleep apnea . Which of the following information should the nurse include in the teaching ? it delivers a preset amount of inspiratory pressure at the beginning of each breath. It has a continuous adjustment feature that changes the airway pressure throughout the cycle. It delivers a preset amount of airway pressure throughout the breathing cycle. It delivers positive pressure at the end of each breath.
It delivers a preset amount of airway pressure throughout the breathing cycle. Nasal CPAP, a common therapeutic intervention for sleep apnea, delivers the same amount of positive airway pressure continuously during all inspiration and expiration cycles. It keeps the trachea and upper airway open while the client is asleep.
A nurse is caring for a client who is hyperventilating and has the following ABG results : pH 7.50 , PaCO 29 mm Hg , and HCO 25 mEq / L . The nurse should recognize that the client has which of the following acid - base imbalances ? Respiratory acidosis Respiratory alkalosis metabolic acidosis metabolic alkalosis
Respiratory alkalosis Hyperventilation causes respiratory alkalosis because the client is exhaling excessive amounts of carbon dioxide. Carbon dioxide loss decreases the hydrogen ion concentration, causing the pH to increase and resulting in respiratory alkalosis.
A nurse is planning care for a client who has acute post - streptococcal glomerulonephritis . Which of the following interventions should the nurse include in the client's plan ? encourage a high protein diet for the client increase the clients fluid intake administer diuretics to the client weight the client twice a week
administer diuretics to the client The management of glomerulonephritis focuses on relieving manifestations. Sodium and fluid restriction and diuretic therapy help reduce the edema that characterizes glomerulonephritis.
a rn is planning care for a group of post clients. which of the following interventions should the rn identify as a priority? administer iv pain meds to a client who reports pain as a 6/10 administer O2 ro a client who has a O2 sat of 91% instruct a client who is 1 hr post ab coughing and deep breathing exercises initiate an infusion of 0.9% sodium chloride for a client who has just had and sx
administer oxygen to a client who had an oxygen saturation of 91% When using the airway, breathing, circulation approach to client care, the nurse should identify that the priority intervention is administering oxygen. Postoperatively, the client's oxygen saturation should be at or above 95%.
A nurse is assessing a client who has meningitis . The nurse should identify which of the following finding as a positive Kerning s sign ? after stroking the later area of the foot, the clients toes contract and draw together after hip flexion, the client is unable to extend their leg completely without pain the client's voluntary movement is not coordinated the client reports pain and stiffness when flexing their neck
after hip flexion, the client is unable to extend their leg completely without pain A client who is unable to extend their leg completely without pain after hip flexion is demonstrating a positive Kernig's sign, which indicates the presence of meningeal irritation.
a nurse is caring for a client who has a new dx go TB. which of the following precautions should the rn initiate to prevent transmission of the disease? contact airborne droplet protective
airborne precautions Tuberculosis is spread through small droplets, measuring less than 5 microns, which can remain airborne for extended periods. The nurse should place a client who has tuberculosis under airborne precautions to prevent the spread of microbes. For airborne precautions, the client should be placed in a private, negative pressure room with 6 to 12 air exchanges per hour with HEPA filtration. The nurse should wear an N95 respirator while providing care to the client. The nurse should also teach the client to cough and expectorate sputum into tissues, which are disposed of in a waterproof sack.
A nurse is assessing a client who has a heart rate of 40 / min . The client is diaphoretic and has chest pain . Which of the following medications should the nurse plan to administer ? lidocaine adenosine atropine verapamil
atropine The client has bradycardia and manifestations that indicate reduced cardiac output. Atropine increases heart rate by blocking the cardiac muscarinic receptors and inhibiting the parasympathetic nervous system. When the heart rate increases, the cardiac output will also increase.
A nurse is reviewing the medical record of a client who has unstable angina . Which of the findings should the nurse report to the provider ? breath sounds (bilateral breath sounds with crackles hears at bases of lungs) Temperature (38 C (100.4 F)) blood pressure (106/62 mm Hg) creatine kinase (100 units/L)
breath sounds The nurse should identify that the client has manifestations of left ventricular failure and pulmonary edema due to decreased cardiac output and reduced cardiac perfusion. These manifestations include cool, clammy skin; pallor; decreased urine output; decreased peripheral pulses; tachypnea; tachycardia; and crackles heard in the bases of the lungs. The client is at risk for cardiogenic shock, so the nurse should report these findings to the provider immediately.
A nurse is providing discharge teaching for a client who has COPD about nutrition . Which of the following instructions should the nurse include ? eat there large meals daily consume high calorie foods limit caffeinated drinks to 2 per day drink fluids during meal time
consume high calorie foods The nurse should instruct the client to consume high-calorie, high-protein foods to provide energy and prevent weight loss.
A nurse is assessing a client who has a sodium level of 122 mEq / L . Which of the following findings should the nurse expect ? decreased deep-tendon reflexes positive Trousseau's sign hypoactive bowel sounds sticky mucous membranes
decreased deep-tendon reflexes The expected reference range of sodium is 136 to 145 mEq/L. A sodium level of 122 mEq/L indicates hyponatremia. Decreased deep-tendon reflexes occur with hyponatremia. Other manifestations of hyponatremia include headache, confusion, lethargy, fatigue, seizures, and muscle weakness to the point of possible respiratory compromise.
A nurse is caring for a client who has been experiencing repeated tonicclonic seizures over the course of 30 min . After maintaining the client's airway and turning the client on their side , which of the following medications should the nurse administer ? diazepam iv lorazepam PO diltiazem iv clonazepam PO
diazepam iv Diazepam is the medication of choice for a client who has status epilepticus. The nurse should administer the medication to provide emergency treatment because the onset of action is within 10 min.
a rn is preparing to dc a client who has a new dx of CKD. which of the following referrals should the nurse plan to initiate? respiratory therapy hospice care occupational therapy dietary services
dietary services The nurse should initiate a referral for dietary services for a client who has CKD. Clients who have kidney disorders require nutritional monitoring of protein, sodium, and potassium intake and weight management to minimize the progression of the disease.
A nurse is admitting a client who has suspected appendicitis . Which of the following findings should the nurse report to the provider immediately ? distended, board like abd WBC count 15,000/mm^3 rebound tenderness over McBurney's point temperature 37.3 C (99.1 F)
distended, board-like abdomen The greatest risk to the client is injury from a ruptured appendix causing peritonitis. Therefore, the priority finding the nurse should report to the provider is the manifestation of a distended board-like abdomen. Peritonitis, which is an inflammation of the peritoneum and viscera, is a medical emergency.
a rn is teaching a group of clients ab the risk factor for osteoporosis. which o the following should the rn incl as a risk factor for osteoporosis? early menopause history of falls African american race obesity
early menopause A client who goes into early menopause, from natural or surgical causes, is at a greater risk for developing osteoporosis due to the rapid drop in estrogen levels. Decreased estrogen leads to an increase in bone decay and a decrease in the production of osteoclasts that produce new bone. Osteoporosis is the most common metabolic bone disorder that results in low bone density. Osteoporosis occurs when the rate of bone resorption exceeds the rate of bone formation, resulting in fragile bone tissue and subsequent fractures.
A nurse is assessing a client who reports a possible exposure to HIV . Which of the following finding should the nurse identify as an early manifestation of HIV infection ? stomatitis fatigue wasting syndrome lipodysrtophy
fatigue A client who has an early HIV infection can either be asymptomatic or can experience fever, rash, and fatigue. Other early manifestations of HIV are similar to those of viral infections.
a rn in an ed is caring for a client who has sustained multiple injuries. the rn observes the client's thorax moving inward during inspiration and outward during expiration. the rn should suspect which of the following injuries? flail chest hemothroax pulmonary contusion pneumothorax
flail chest Flail chest results from multiple rib fractures that cause instability. The thorax moves inward with inspiration and outward with expiration. This paradoxical chest movement prevents adequate ventilation of the injured lung.
a rn is caring for a client who has a R-sided pneumothorax. following chest tube insertion, which of the following findings indicates that the chest drainage system is functioning correctly? gentle bubbling in the suction chamber crepitus around the insertion site constant bubbling in the water seal chamber absence of breath sounds on the right side
gentle bubbling in the suction chamber Bubbling in the suction chamber is expected and indicates that the drainage system is connected to suction.
A nurse is caring for a client who has rheumatoid arthritis and has been taking prednisone . Which of the following findings should the nurse identify as an adverse effect of this medication ? weight loss hypoglycemia hypertension hyperkalemia
hypertension The nurse should identify that hypertension is an adverse effect of prednisone, which is a corticosteroid. The nurse should notify the provider for further evaluation if the client has hypertension.
a rn in a rural community center is providing education to a group of clients ab first aid interventions for snake bites to prevent further injury. which of the following instructions should the rn incl in the teaching? apply an ice pack directly to the affected area immobilize the affected extremity w a splint place a tourniquet above and below the affected area elevate the affected extremity
immobilize the affected extremity w a splint The nurse should instruct the clients to immobilize the affected extremity below the level of the heart with a splint.
A nurse is providing discharge teaching to a client who has heart failure and a prescription for furosemide 20 mg PO two times daily . Which of the following instructions should the nurse include in the teaching ? monitor for increased BP increase intake of high potassium foods expect an increase in swelling in the hands and feet take the second dose at bedtime
increase intake of high potassium foods The nurse should instruct the client that hypokalemia is an adverse effect of furosemide. The client should increase their intake of high-potassium foods.
A nurse is caring for a client who has increased intracranial pressure (ICP). Which of the following interventions should the nurse implement? place several pillows behind the clients head place the client in sims postion keep the client's neck in a midline position maintain flexion of the client's hips at a 90 degree angle
keep the client's neck in a midline position When positioning a client who has increased ICP, it is important to maintain the neck in a midline position. This promotes optimal blood flow and reduces the risk for increased ICP.
A nurse is providing dietary teaching for a client who has chronic cholecystitis. Which of the following diets should the nurse recommend ? low potassium diet high fiber diet low fat diet low sodium diet
low fat diet The nurse should instruct a client who has chronic cholecystitis to consume a low-fat diet to reduce episodes of biliary colic.
A nurse is planning care for a client who has acute pancreatitis . Which of the following interventions should the nurse include in the clients plan ? SATA initiate insulin drip monitor blood glucose levels continue regular diet as tolerated maintain NPO status until pain free manage cute pain
monitor blood glucose levels maintain NPO status until pain free manage cute pain The client is at risk for hyperglycemia. The nurse should monitor the client's blood glucose levels and provide insulin as needed. The client should remain NPO until pain-free to decrease the secretion of pancreatic enzymes, which should result in decreasing inflammation of the pancreas. Continuing a regular diet will only increase the secretion of pancreatic enzymes and cause further inflammation and pain. Classic manifestations of an acute attack include severe, constant, and knife-like pain. The client will require pain medication to treat the pain, decrease gastrointestinal tract activity, and reduce pancreatic stimulation during the acute exacerbation phase.
A nurse is developing a plan of care for a client who will be placed in halo traction following surgical repair of the cervical spine .Which of the following interventions should the nurse include in the plan ? inspect the pin site every 49 hr monitor the client's skin under the halo vest ensure 2 personnel would the halo device when repositioning the client apply powder frequently to the client's skin under the vest to decrease itching
monitor the client's skin under the halo vest The nurse should monitor the client's skin that is under the halo vest for excessive sweating, redness, or blistering, which can lead to skin breakdown and infection. To ensure the vest is not causing pressure, the nurse should be able to insert one finger between the jacket and the skin with ease.
A home health nurse is providing teaching to the family of a client who has a seizure disorder . Which of the following interventions should the nurse include the teaching ? keep a padded tongue blade near the bedside place a pillow under the client's head while in bed during a seizure administer diazepam orally at the onset of seizures position the client on their side during the seizure
position the client on their side during the seizure Clients who have seizures are at risk for injury and aspiration. Therefore, the nurse should instruct the family to place the client on their side during a seizure to keep the airway patent.
a rn is caring for a client who has chronic kidney disease. which of the following diets should the rn anticipate the provider to rx? 4 g sodium diet potassium restricted diet high phosphorus diet high protein diet
potassium restricted diet Clients who have chronic kidney disease should be encouraged to consume a diet that is low in potassium and protein. The nurse should consult the provider for an appropriate diet prescription.
A nurse is preparing a client for a colonoscopy . Which of the following medications should the nurse anticipate the provider prescribe as an anesthetic for the procedure ? propofol pancuronium promethazine pentoxifylline
propofol The nurse should identify that propofol is a short-acting anesthetic medication that can be used to cause moderate sedation for procedures, such as a colonoscopy.
a rn is planning care for a client who has meniere's disease and is experiencing epodes of vertigo. which of the following interventions should the rn include in the plan? maintain strict bed rest restrict fluid intake to the morning hours administer aspirin provide a low-sodium diet
provide a low sodium diet Ménière's disease is an inner ear disorder that affects the client's balance. Limiting sodium in the diet reduces fluid retention, which decreases the manifestations of the disease.
A nurse is teaching a group of assistive personnel ( AP ) about caring for client who have Alzheimer's disease . Which of the following information should the nurse include in the teaching ? explain procedure in full detail to a client before initiating care limit a clients activities to minimize emotional outbursts speak Cleary and loudly to a client who is unable to form words or sentences provide supervision to prevent a client from becoming injured or lost
provide supervision to prevent a client from becoming injured or lost A client who has Alzheimer's disease can wander and become lost. The AP should initiate interventions to keep the client safe, such as redirection, frequent monitoring, and reorientation.
A nurse is caring for a client who is at high risk for iron deciency anemia Which of the following foods should the nurse instruct the client to increase in their diet ? yogurt apples raisins cheddar cheese
raisins The nurse should instruct the client to increase consumption of raisins, which is a good source of iron, because ¼ cup of raisins contains 1.08 mg of iron. Other good food sources of iron include dried fruits, red meat, fortified whole grains, and green leafy vegetables.
A nurse is caring for a client who has a traumatic brain injury . Which of the following finding should indicate to the nurse the need for immediate intervention ? axillary temperature 37.c C (99 F) apical pulse 100/min respiratory rate 30/min blood pressure 140/84 mm Hg
respiratory rate 30/min When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is the client's airway and breathing pattern. Following a head injury, the client is at risk for increased intracranial pressure, which can result from CO2 retention. The body attempts to compensate for the resulting decrease in pH by using hyperventilation to expel excess CO2 and correct the imbalance.
A nurse is providing discharge teaching to a client following a heart transplant . Which of the following information should the nurse include in the teaching ? Immunosuppressant meds need to be taken for up to 1 yr shortness of breath might be an indication of transplant rejection the surgical site will heal in 3 to 4 weeks after sx begin 45 min of moderate aerobic exercise per day following dc
shortness of breath might be an indication of transplant rejection Shortness of breath is an indication of transplant rejection. Other manifestations include fatigue, edema, bradycardia, and hypotension. Clients who have had an organ transplant should be educated on the manifestations of rejection and when to contact their provider.
a rn is administering a blood transfusion to a client and suspects that the client is having an adverse reaction to the blood. which of the following actions should the nurse take first? maintain IV access obtain the clients vitals contact the provider stop the transfusion
stop the transfusion The greatest risk to this client is injury from the adverse effects caused by receiving the blood. Therefore, the first action the nurse should take is to stop the infusion.
a rn is caring for a client who has a PICC. for which of the following findings should the rn notify the provider? the dressing was changed 7 days ago the circumference of the client's upper arm has increased by 10% the catheter has not been used in 8 hr the catheter has been flushed with 10 ml of sterile saline after each med use
the circumference of the client's upper arm has increased by 10% Circumference of the upper arm above the insertion site of the PICC should be measured at the time of insertion and then again during assessments. An increase in the circumference could indicate deep-vein thrombosis, which could be life threatening. The nurse should contact the provider immediately about this finding.
A nurse is caring for a client who syndrome of inappropriate antidiuretic hormone ( SIADH ) and is receiving 3 % sodium chloride via continuous IV . Which of the following laboratory finding should the nurse identify as an indication that the SIADH is resolving urine specific gravity 1.020 sodium 119 mEq/L BUN 8 mg/dL Calcium 8.7 mg/dL
urine specific gravity 1.020 A client who has SIADH has a decreased urine output with increased concentration, resulting in an elevation in the specific gravity. The nurse should recognize that a urine specific gravity of 1.020 is within the expected reference range of 1.005 to 1.030, indicating a resolution of SIADH.
A nurse is providing discharge teaching to a client who has acute leukemia and received chemotherapy 12 hr ago . Which of the following instructions should the nurse include in the teaching ? SATA use an electric shaver avoid crowds take temperature weekly consume a low residue diet monitor for bruising
use an electric shaver avoid crowds monitor for bruising Chemotherapy is myelosuppressive, causing a potential decrease in all blood cell counts. Acute leukemia is cancer of the blood and affects bone marrow production of blood cells. Therefore, the client is at risk for a decrease in platelet count, and bleeding precautions should be instituted. Twelve hours following chemotherapy, the client's WBC count is likely low, and there is an increased risk for infection. Crowds should be avoided if possible. The client should monitor for bruising and other indications of bleeding.
A nurse is caring for a client who has dehydration . The client has a peripheral IV and has a prescription for an infusion of 0.9 % sodium chloride 1,000 mL with 40 mEq potassium chloride to infuse over 1 hr . Which of the following actions should the nurse take first ? teach the client to report findings go iv extravasation evaluate the potency of the iv consult with the pharmacist ab the rx verify the rx with the provider
verify the prescription with the provider The greatest risk to the client is injury from fluid volume overload and dysrhythmia from the potassium in the IV solution infusing too rapidly. Therefore, the priority action the nurse should take is to verify the prescription with the provider. The nurse should infuse intravenous fluid containing potassium at a rate of no greater than 10 mEq/hr to prevent dysrhythmias.
