AH IV Exam 3
A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider's prescription? 1.Endotracheal intubation 2.100 units of NPH insulin 3.Intravenous infusion of normal saline 4.Intravenous infusion of sodium bicarbonate
3
A client is experiencing the syndrome of inappropriate antidiuretic hormone (ADH) secretion. When explaining this disorder to the client and family, the nurse recalls that ADH works to reabsorb water in which parts of the nephron? 1.The glomerulus and the calices 2.The loop of Henle and the distal tubule 3.The distal tubule and the collecting duct 4.The proximal tubule and the loop of Henle
3
A client with diabetes insipidus asks the nurse about the purpose of a new medication, vasopressin. The nurse provides teaching about the medication. Which statement by the client indicates successful teaching? 1."It causes muscle contractions." 2."It opens up my blood vessels." 3."It prevents me from 'peeing' so much." 4."It decreases stomach and colon motility."
3
A nurse is assessing a client who has had cranial surgery and is at risk for development of diabetes insipidus. The nurse would assess for which signs or symptoms that could indicate development of this complication? 1.Diarrhea 2.Infection 3.Polydipsia 4.Weight gain
3
The nurse teaches a client newly diagnosed with type 1 diabetes about storing Humulin N insulin. Which statement indicates to the nurse that the client understood the discharge teaching? 1."I should keep the insulin in the cabinet during the day only." 2."I know I have to keep my insulin in the refrigerator at all times." 3."I can store the open insulin bottle in the kitchen cabinet for 1 month." 4."The best place for my insulin is on the windowsill, but in the cupboard is just as good."
3
A 63-year-old client with type 2 diabetes mellitus is admitted for treatment of an ulcer on the heel of the left foot that has not healed with wound care. The nurse observes that the entire left foot is darker in color than the right foot. Which additional symptom should the nurse expect to find? A. Pedal pulses will be weak or absent in the left foot. B. The client will state that the left foot is usually warm. C. Flexion and extension of the left foot will be limited. D. Capillary refill of the client's left toes will be brisk
A
Glimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply. 1.Alcohol 2.Red meats 3.Whole-grain cereals 4.Low-calorie desserts 5.Carbonated beverages
2,3,5 When alcohol is combined with glimepiride, a disulfiram-like reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. Low-calorie desserts should also be avoided. Even though the calorie content may be low, carbohydrate content is most likely high and can affect the blood glucose. The items in options 2, 3, and 5 are acceptable to consume.
A client is at risk for developing disseminated intravascular coagulopathy (DIC). The nurse determines that which fibrinogen level is normal? 1.170 mg/dL (1.7 g/L) 2.400 mg/dL (4.0 g/L) 3.480 mg/dL (4.8 g/L) 4.500 mg/dL (5.0 g/L)
2. The normal fibrinogen level is 200 to 400 mg/dL (2 to 4 g/L). With DIC, the fibrinogen level drops because fibrinogen is used up in the clotting process. The correct option is the only one that identifies a normal level.
Metformin is prescribed for a client with type 2 diabetes mellitus. What is the most common side effect that the nurse should include in the client's teaching plan? 1.Weight gain 2.Hypoglycemia 3.Flushing and palpitations 4.Gastrointestinal disturbances
4 The most common side effect of metformin is gastrointestinal disturbances, including decreased appetite, nausea, and diarrhea. These generally subside over time. This medication does not cause weight gain; clients lose an average of 7 to 8 lb (3.2 to 3.6 kg) because the medication causes nausea and decreased appetite. Although hypoglycemia can occur, it is not the most common side effect. Flushing and palpitations are not specifically associated with this medication.
The nurse caring for a client who underwent intracranial surgery is suspected of having diabetes insipidus. Which finding noted by the nurse is consistent with this complication of surgery? 1.Complaints of excessive thirst 2.Urine specific gravity of 1.030 3.Urine output of 10 to 15 mL/hour 4.Systolic blood pressures running consistently over 150 mm Hg
1
The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? 1.Polyuria 2.Diaphoresis 3.Pedal edema 4.Decreased respiratory rate
1 Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of diabetes mellitus. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of diabetes mellitus; however, it does not predispose a client to the chronic complications of diabetes mellitus. Therefore, option 2 can be eliminated because this finding is characteristic of hypoglycemia. Options 3 and 4 are not associated with diabetes mellitus.
The primary health care provider (PHCP) prescribes exenatide for a client with type 1 diabetes mellitus who takes insulin. The nurse should plan to take which most appropriate intervention? 1.Withhold the medication and call the PHCP, questioning the prescription for the client. 2.Teach the client about the signs and symptoms of hypoglycemia and hyperglycemia. 3.Monitor the client for gastrointestinal side effects after administering the medication. 4.Withdraw the insulin from the prefilled pen into an insulin syringe to prepare for administration.
1 Exenatide is an incretin mimetic used for type 2 diabetes mellitus only. It is not recommended for clients taking insulin. Hence the nurse should withhold the medication and question the PHCP regarding this prescription. Although options 2 and 3 are correct statements about the medication, in this situation the medication should not be administered. The medication is packaged in prefilled pens ready for injection without the need for drawing it up into another syringe.
A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the primary health care provider (PHCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? 1.The client needs immediate education before discharge. 2.The client requires follow-up teaching regarding the administration of oral antidiabetics. 3.The client's statement is inaccurate, and he or she should be scheduled for outpatient diabetic counseling. 4.The client's statement is inaccurate, and he or she should be scheduled for educational home health visits.
1 If the client becomes ill and cannot retain fluids or food for a period of 4 hours, the PHCP should be notified. The client's statement indicates a need for immediate education to prevent hyperosmolar hyperglycemic syndrome (HHS), a life-threatening emergency. Although all of the other options may be true, the most appropriate analysis is that the client requires immediate education
The nurse is teaching a client with diabetes mellitus how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? 1.Withdraws the NPH insulin first 2.Withdraws the regular insulin first 3.Injects air into NPH insulin vial first 4.Injects an amount of air equal to the desired dose of insulin into each vial
1 When preparing a mixture of short-acting insulin, such as regular insulin, with another insulin preparation, the short-acting insulin is drawn into the syringe first. This sequence will avoid contaminating the vial of short-acting insulin with insulin of another type. Options 2, 3, and 4 identify correct actions for preparing NPH and short-acting insulin.
A hospitalized client is diagnosed with type 1 diabetes mellitus. The nurse plans care for the client, understanding that which factors are likely causes of the beta cell destruction that accompanies this disorder? Select all that apply. 1.Viruses 2.Genetic factors 3.Autoimmune factors 4.Human leukocyte antigen (HLA) 5.Primary failure of glucagon secretion
1,2,3,4 Viruses and autoimmune factors are thought to play a role in the development of type 1 diabetes mellitus. Other causes of type 1 diabetes mellitus include genetic factors, specifically the presence of HLA. This factor is found in many clients with type 1 diabetes mellitus. The problem with type 1 diabetes mellitus is destruction of the beta cells. It is not caused by a primary failure of glucagon secretion.
A nurse is reviewing the assessment findings for a client who was admitted to the hospital with a diagnosis of diabetes insipidus. The nurse understands that which manifestations are associated with this disorder? Select all that apply. 1.Polyuria 2.Polydipsia 3.Concentrated urine 4.Complaints of excessive thirst 5.Specific gravity lower than 1.005
1,2,4,5. A triad of clinical symptoms-polyuria, polydipsia, and excessive thirst-often occurs suddenly in the client with diabetes insipidus. The urine is dilute, with a specific gravity lower than 1.005, and the urine osmolality is low (50 to 200 mOsm/L).
A client with diabetes mellitus is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. 1.Hypoglycemia may be experienced before dinnertime. 2.The insulin dose should be decreased if illness occurs. 3.The insulin should be administered at room temperature. 4.The insulin vial needs to be shaken vigorously to break up the precipitates. 5.The NPH insulin should be drawn into the syringe first, then the regular insulin.
1,3 Humulin NPH is an intermediate-acting insulin. The onset of action is 60 to 120 minutes, it peaks in 6 to 14 hours, and its duration of action is 16 to 24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 30 to 60 minutes, it peaks in 1 to 5 hours, and its duration is 6 to 10 hours. Hypoglycemic reactions most likely occur during peak time. Insulin should be at room temperature when administered. Clients may need their insulin dosages increased during times of illness. Insulin vials should never be shaken vigorously. Regular insulin is always drawn up before NPH.
The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. 1.Tremors 2.Anorexia 3.Irritability 4.Nervousness 5.Hot, dry skin 6.Muscle cramps
1,3,4 Decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 5 is more likely to occur with hyperglycemia. Options 2 and 6 are unrelated to the manifestations of hypoglycemia. In hypoglycemia, usually the client feels hunger
The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which primary health care provider prescriptions should the nurse anticipate receiving? Select all that apply. 1.Initiate an infusion of 3% NaCl. 2.Administer intravenous furosemide. 3.Restrict fluids to 800 mL over 24 hours. 4.Elevate the head of the bed to high-Fowler's. 5.Administer a vasopressin antagonist as prescribed.
1,3,5. Clients with SIADH experience excess secretion of antidiuretic hormone (ADH), which leads to excess intravascular volume, a declining serum osmolarity, and dilutional hyponatremia. Management is directed at correcting the hyponatremia and preventing cerebral edema. Hypertonic saline is prescribed when the hyponatremia is severe, less than 120 mEq/L (120 mmol/L). When furosemide is used, potassium supplementation should also occur and serum potassium levels should be monitored. To promote venous return, the head of the bed should not be raised more than 10 degrees for the client with SIADH. Maximizing venous return helps avoid stimulating stretch receptors in the heart that signal to the pituitary that more ADH is needed.
Which findings should raise suspicion to the nurse that a head-injured client may be experiencing diabetes insipidus? Select all that apply. 1.Urine specific gravity is 1.001. 2.Ketones are present in the urine. 3.Jugular venous distention is observed. 4.Serum osmolality is 320 mOsm/kg (320 mmol/kg) of water. 5.Blood glucose levels are greater than 200 mg/dL (11.4 mmol/L). 6.Urine output has increased from 1000 mL in 24 hours to 4000 mL in 24 hours.
1,4,6. Signs of diabetes insipidus include low urine specific gravity (<1.005), high serum osmolality (>300 mOsm/kg of water), and increased urine output from a deficiency of antidiuretic hormone (ADH). Options 2, 3, and 5 are not characteristic of diabetes insipidus.
The nurse is caring for a client hospitalized for heart failure exacerbation and suspects the client may be entering a state of shock. The nurse knows that which intervention is the priority for this client? 1.Administration of digoxin 2.Administration of whole blood 3.Administration of intravenous fluids 4.Administration of packed red blood cells
1. The client in this question is likely experiencing cardiogenic shock secondary to heart failure exacerbation. It is important to note that if the shock state is cardiogenic in nature, the infusion of volume-expanding fluids may result in pulmonary edema; therefore, restoration of cardiac function is the priority for this type of shock. Cardiotonic medications such as digoxin, dopamine, or norepinephrine may be administered to increase cardiac contractility and induce vasoconstriction. Whole blood, intravenous fluids, and packed red blood cells are volume-expanding fluids and may further complicate the client's clinical status; therefore, they should be avoided.
A client is seen in the clinic for complaints of thirst, frequent urination, and headaches. After diagnostic studies, diabetes insipidus is diagnosed. Desmopressin is prescribed. The client asks why this medication was prescribed. Which is a correct statement by the nurse? 1."It relieves the headaches." 2."It increases water reabsorption." 3."It stimulates the production of aldosterone." 4."It decreases the production of the antidiuretic hormone."
2
A client with a history of coronary artery disease has developed diabetes insipidus as a result of cranial surgery. The client's medication therapy will include vasopressin. The nurse monitors this client most carefully for which sign or symptom that indicates a side or adverse effect of this medication? 1.Depression 2.Chest pain 3.Joint stiffness 4.Nagging cough
2
The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? 1.Lack of knowledge 2.Inadequate fluid volume 3.Compromised family coping 4.Inadequate consumption of nutrients
2 An increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 1, 3, and 4 are not related specifically to the information in the question
A client with myocardial infarction is developing cardiogenic shock. What condition should the nurse carefully assess the client for? 1.Pulsus paradoxus 2.Ventricular dysrhythmias 3.Rising diastolic blood pressure 4.Falling central venous pressure
2 Dysrhythmias commonly occur as a result of decreased oxygenation and severe damage to greater than 40% of the myocardium. Classic signs of cardiogenic shock as they relate to myocardial ischemia include low blood pressure and tachycardia. The central venous pressure would rise as the backward effects of the severe left ventricular failure became apparent. Pulsus paradoxus is a finding associated with cardiac tamponade
A client with diabetes mellitus visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180 to 200 mg/dL (10 to 11.1 mmol/L). Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? 1.Atenolol 2.Prednisone 3.Phenelzine 4.Allopurinol
2 Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 1, a beta blocker, and option 3, a monoamine oxidase inhibitor, have their own intrinsic hypoglycemic activity. Option 4 decreases urinary excretion of sulfonylurea agents, causing increased levels of the oral agents, which can lead to hypoglycemia
The clinic nurse is providing instructions to a client with diabetes mellitus about the signs and symptoms of hypoglycemia. The nurse should tell the client that which would be noted in a hypoglycemic reaction? 1.Thirst 2.Hunger 3.Polydipsia 4.Increased urine output
2 Signs and symptoms of hypoglycemia include hunger, nervousness, anxiety, dizziness, blurred vision, sweaty palms, confusion, and tingling and numbness around the mouth. Polydipsia (thirst) and increased urine output are noted in the client with hyperglycemia.
A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply 1. Increase in pH 2.Comatose state 3.Deep, rapid breathing 4.Decreased urine output 5.Elevated blood glucose level
2,3,5 Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid by-products of fat metabolism, build up, and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide (CO2), which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect, because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client will experience polyuria.
The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptoms develop? Select all that apply. 1.Polyuria 2.Shakiness 3.Palpitations 4.Blurred vision 5.Lightheadedness 6.Fruity breath odor
2,3,5 Shakiness, palpitations, and lightheadedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and a fruity breath odor are manifestations of hyperglycemia
The nurse teaches the client who is newly diagnosed with diabetes insipidus about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply. 1."This medication will turn my urine orange." 2."I should decrease my oral fluids when I start this medication." 3."The amount of urine I make should increase if this medicine is working." 4."I need to follow a low-fat diet to avoid pancreatitis when taking this medicine." 5."I should report headache and drowsiness to my doctor since these symptoms could be related to my desmopressin."
2,5. In diabetes insipidus, there is a deficiency in antidiuretic hormone (ADH), resulting in large urinary losses. Desmopressin is an antidiuretic hormone that enhances reabsorption of water in the kidney. Clients with diabetes insipidus drink high volumes of fluid (polydipsia) as a compensatory mechanism to counteract urinary losses and maintain fluid balance. Once desmopressin is started, oral fluids should be decreased to prevent water intoxication. Therefore, clients with diabetes insipidus should decrease their oral fluid intake when they start desmopressin. Headache and drowsiness are signs of water intoxication in the client taking desmopressin and should be reported to the primary health care provider. Desmopressin does not turn urine orange. The amount of urine should decrease, not increase, when desmopressin is started. Desmopressin does not cause pancreatitis.
An adult male client admitted to the hospital with shock has received fluid volume replacement. The nurse should determine that the client has had adequate fluid resuscitation if the client's repeat hematocrit level has decreased to which value in the normal range? 1.56% (0.56) 2.48% (0.48) 3.37% (0.38) 4.34% (0.34)
2. The normal hematocrit level for an adult male is 42% to 52% (0.42 to 0.52). The client who is in shock has an elevated level because of hemoconcentration. The client's level may be expected to drift back down to within the normal range once fluid volume has been adequately restored. Thus, 48% (0.48) is the only correct choice; 56% (0.56) is too high, and 34% (0.34) and 37% (0.37) are low.
A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.3 mmol/L). The nurse would next prepare to administer which medication? 1.An ampule of 50% dextrose 2.NPH insulin subcutaneously 3.IV fluids containing dextrose 4.Phenytoin for the prevention of seizures
3 Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (13.9 to 16.7 mmol/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL (13.9 mmol/L), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not a usual treatment measure for DKA
The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101º F (38.3º C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? 1.Pulse 2.Respiration 3.Temperature 4.Blood pressure
3 In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus. The other findings are within normal limits.
The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 70 mg/dL (3.9 mmol/L). Which finding would be the priority concern to the nurse? 1.Pulse 2.Respiration 3.Temperature 4.Blood pressure
3 In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus. The other findings are within normal limits.
The nurse is providing discharge teaching for a client newly diagnosed with type 2 diabetes mellitus who has been prescribed metformin. Which client statement indicates the need for further teaching? 1."It is okay if I skip meals once in a while." 2."I need to let my doctor know if I get unusually tired." 3."I need to constantly watch for signs of low blood sugar." 4."I will be sure to not drink alcohol excessively while on this medication."
3 Metformin is classified as a biguanide and is the most commonly used medication for type 2 diabetes mellitus initially. It is also often used as a preventive medication for those at high risk for developing diabetes mellitus. When used alone, metformin lowers the blood glucose after meal intake as well as fasting blood glucose levels. Metformin does not stimulate insulin release and therefore poses little risk for hypoglycemia. For this reason, metformin is well suited for clients who skip meals. Unusual somnolence as well as hyperventilation, myalgia, and malaise are early signs of lactic acidosis, a toxic effect associated with metformin. If any of these signs or symptoms occur, the client should inform the primary health care provider immediately. While it is best to avoid consumption of alcohol, it is not always realistic or feasible for clients to quit drinking altogether; for this reason, clients should be informed that excessive alcohol intake can cause an adverse reaction with metformin.
The nurse is providing instructions regarding insulin administration for a client newly diagnosed with diabetes mellitus. The primary health care provider has prescribed a mixture of NPH insulin and regular insulin. The nurse should instruct the client that which is the first step in this procedure? 1.Draw up the correct dosage of NPH insulin into the syringe. 2.Draw up the correct dosage of regular insulin into the syringe. 3.Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. 4.Inject air equal to the amount of regular insulin prescribed into the vial of regular insulin.
3 The initial step in preparing an injection of insulin that is a mixture of NPH and regular insulin is to inject air into the NPH insulin bottle equal to the amount of insulin prescribed. The client would then be instructed to inject an amount of air equal to the amount of prescribed insulin into the regular insulin bottle. The regular insulin would then be withdrawn, followed by the NPH insulin. Contamination of regular insulin with NPH insulin will convert part of the regular insulin into a longer acting form
A nurse is reviewing the assessment findings and laboratory data for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse understands that which symptoms are associated characteristics of this disorder? Select all that apply. 1.Hypernatremia 2.Signs of water deficit 3.High urine osmolality 4.Low serum osmolality 5.Hypotonicity of body fluids 6.Continued release of antidiuretic hormone (ADH)
3,4,5,6. SIADH is characterized by inappropriate continued release of ADH. This results in water intoxication, manifested as fluid volume expansion, hypotonicity of body fluids, and hyponatremia as a result of the high urine osmolality and low serum osmolality.
Which clinical findings are consistent with sepsis diagnostic criteria? Select all that apply. 1.Urine output 50 mL/hr 2.Hypoactive bowel sounds 3.Temperature of 102° F (38.9° C) 4.Heart rate of 96 beats per minute 5.Mean arterial pressure 65 mm Hg 6.Systolic blood pressure 110 mm Hg
3,4,5. Sepsis diagnostic criteria with regard to signs and symptoms include the following: Fever (temperature higher than 100.9° F [38.3° C]) or hypothermia (core temperature lower than 97° F [36° C]), tachycardia (heart rate above 90 beats per minute), tachypnea (respiratory rate above 22 breaths per minute), systolic blood pressure (SBP) less than or equal to 100 mm Hg, altered mental status, edema or positive fluid balance, oliguria, ileus (absent bowel sounds), and decreased capillary refill or mottling of skin.
The nurse overhears a primary health care provider (PHCP) stating that a client diagnosed with disseminated intravascular coagulation (DIC) requires a transfusion. Which blood product should the nurse anticipate that the PHCP will write a prescription for? 1.Albumin 2.Platelets 3.Cryoprecipitate 4.Packed red blood cells
3. Cryoprecipitate is useful in treating bleeding from hemophilia or DIC because it is rich in clotting factors. Albumin may be used as a plasma expander in hypovolemia with or without shock. Platelets are used when the client's platelet count is low. Packed red blood cells replace erythrocytes, not fibrinogen
Vasopressin is prescribed for a client with diabetes insipidus. The nurse should be particularly cautious in monitoring a client receiving this medication if the client has which preexisting condition? 1.Depression 2.Endometriosis 3.Pheochromocytoma 4.Coronary artery disease
4
The nurse is reviewing the primary health care provider's (PHCP's) prescriptions for a client with a diagnosis of diabetes mellitus who has been hospitalized for treatment of an infected foot ulcer. The nurse expects to note which finding in the PHCP's prescriptions? 1.A decreased-calorie diet 2.An increased-calorie diet 3.A decreased amount of NPH insulin daily insulin 4.An increased amount of NPH insulin daily insulin
4 Infection is a physiological stressor that can cause an increase in the level of epinephrine in the body. An increase in epinephrine causes an increase in blood glucose levels. When the client is under stress, such as when an infection is present, an increase in the dose of insulin will be required to facilitate the transport of excess glucose into the cells. The client will not necessarily need an adjustment in the daily diet
The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? 1.Correct the acidosis. 2.Administer 5% dextrose intravenously. 3.Apply a monitor for an electrocardiogram. 4.Administer short-duration insulin intravenously.
4 Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short- or rapid-acting), intravenous fluid administration (normal saline initially, not 5% dextrose), and potassium replacement, followed by correcting acidosis. Cardiac monitoring is important due to alterations in potassium levels associated with DKA and its treatment, but applying an electrocardiogram monitor is not the priority action.
A test to measure long-term control of diabetes mellitus has been prescribed for a client. In instructing the client about the test, the nurse explains that long-term control can be measured because chronic high blood glucose levels lead to irreversible glucose binding onto what? 1.Platelets 2.Muscle tissue 3.Adipose tissue 4.Red blood cells (RBCs)
4 With chronic high circulating blood glucose levels, some glucose binds irreversibly onto RBCs and remains there for the life of the cell. The average life span of an RBC is 120 days. The measurement of glycosylated hemoglobin A (HbA1c), which detects glucose binding on the RBC membrane, is expressed as a percentage. Glucose does not bind onto platelets in diabetes mellitus. One of the problems in diabetes is that muscle and adipose cells may be unable to transport glucose across cell membranes
A client in shock develops a central venous pressure (CVP) of 2 mm Hg. Which prescribed intervention should the nurse implement first? 1.Increase the rate of O2 flow 2.Obtain arterial blood gas results 3.Insert an indwelling urinary catheter 4.Increase the rate of intravenous (IV) fluids
4. The MAP and CVP are both low for this client, indicating a shock state. Shock is the result of inadequate tissue perfusion. Fluid volume should be immediately restored first to provide adequate perfusion for the client in a shock state. Although increasing the rate of O2 flow may be a necessary intervention, perfusion is the first priority. Obtaining arterial blood gas results and inserting an indwelling urinary catheter may be necessary interventions to monitor the client's response to prescribed therapy, but these are not the priority
A client in cardiogenic shock has a pulmonary artery catheter (Swan-Ganz type) placed. The nurse would interpret which cardiac output (CO) and pulmonary capillary wedge pressure (PCWP) readings as indicating that the client is most unstable? 1.CO 5 L/min, PCWP low 2.CO 3 L/min, PCWP low 3.CO 4 L/min, PCWP high 4.CO 3 L/min, PCWP high
4. The normal cardiac output is 4 to 7 L/min. With cardiogenic shock, the CO falls below normal because of failure of the heart as a pump. The PCWP, however, rises because it is a reflection of the left ventricular end-diastolic pressure, which rises with pump failure.
A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, I am experiencing right flank pain and have a temperature of 101 F. How should the nurse respond? a. The anti-rejection drugs you are taking make you susceptible to infection. b. You should go to the hospital immediately to have your new liver checked out. c. You should take an additional dose of cyclosporine today. d. Take acetaminophen (Tylenol) every 4 hours until you feel better.
ANS: B Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.
An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations
ANS: B, D Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion.
A client with type 2 diabetes takes metformin (Glucophage) daily. The client is scheduled for major surgery requiring general anesthesia the next day. The nurse anticipates which approach to manage the client's diabetes best while the client is NPO during the perioperative period? A. NPO except for metformin and regular snacks B. NPO except for oral antidiabetic agent C. Novolin N insulin subcutaneously twice daily D. Regular insulin subcutaneously per sliding scale
D