AH Test #6
A nurse is caring for a patient who has excessive catecholamine release. Which assessment finding would the nurse correlate with this condition? Decreased blood pressure Increased pulse Decreased respiratory rate Increased urine output
Increased pulse
A nurse assesses a client who is admitted for treatment of fluid overload. Which signs and symptoms does the nurse expect to find? (Select all that apply.) Increased pulse rate Distended neck veins Decreased blood pressure Warm and pink skin Skeletal muscle weakness Visual disturbances
Increased pulse rate Distended neck veins Skeletal muscle weakness Visual disturbances
A medical-surgical nurse is concerned about the incidence of complications related to IV therapy, including bloodstream infection. Which intervention will the nurse suggest to the management team to make the biggest impact on decreasing complications? Initiate a dedicated team to insert access devices. Require additional education for all nurses. Limit the use of peripheral venous access devices. Perform quality control testing on skin preparation products.
Initiate a dedicated team to insert access devices.
A client in the emergency department reports that he has been vomiting excessively for the past 2 days. His arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic alkalosis d) Metabolic acidosis
Metabolic alkalosis
A nurse prepares to insert a peripheral venous catheter in an older adult. What action will the nurse take to protect the client's skin during this procedure? Lower the extremity below the level of the heart. Apply warm compresses to the extremity. Tap the skin lightly and avoid slapping. Place a washcloth between the skin and tourniquet.
Place a washcloth between the skin and tourniquet.
A nurse is caring for a client with a peripheral vascular access device who is experiencing pain, redness, and swelling at the site. After removing the device, what action will the nurse take to relieve pain? Administer topical lidocaine to the site. Place warm compresses on the site. Administer prescribed oral pain medication. Massage the site with scented oils.
Place warm compresses on the site.
A nurse is caring for several clients at risk for fluid imbalances. Which laboratory results are paired with the correct potential imbalance? (Select all that apply.) Sodium: 160 mEq/L (mmol/L):Overhydration Potassium: 5.4 mEq/L (mmol/L): Dehydration Osmolarity: 250 mOsm/L: Overhydration Hematocrit: 68%: Dehydration BUN: 39 mg/dL: Overhydration Magnesium: 0.8 mg/dL: Dehydration
Potassium: 5.4 mEq/L (mmol/L): Dehydration Osmolarity: 250 mOsm/L: Overhydration Hematocrit: 68%: Dehydration Magnesium: 0.8 mg/dL: Dehydration
A nurse cares for a client who has a serum potassium of 6.5 mEq/L (6.5 mmol/L) and is exhibiting cardiovascular changes. Which intervention will the nurse implement first? Prepare to administer patiromer by mouth. Provide a heart-healthy, low-potassium diet. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. Prepare the client for hemodialysis treatment.
Prepare to administer dextrose 20% and 10 units of regular insulin IV push.
A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the nurse to decreased kidney function in this client? Urine specific gravity of 1.033 Presence of protein in the urine Elevated capillary blood glucose level Presence of ketone bodies in the urine
Presence of protein in the urine
A nurse cares for a client with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond? "You need to start with multiple injections until you become more proficient at self-injection." "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns." c. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock."
"A single dose of insulin each day would not match your blood insulin levels and your food intake patterns."
A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement would the nurse include in this client's teaching? "Change positions slowly when you get out of bed." "Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)." "If you miss a dose of this drug, you can double the next dose." d. "Discontinue the medication if you develop a urinary infection."
"Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)."
The nurse is planning teaching for a client who is starting acarbose for diabetes mellitus type 2. Which statement will the nurse include in the teaching? "Be sure to take the drug with each meal." "Take the drug every evening before bedtime." "Take the drug on an empty stomach in the morning." "Decide on the best day of the week to take the drug."
"Be sure to take the drug with each meal."
A nurse teaches a client who is at risk for hyponatremia. Which statement does the nurse include in this client's teaching? "Have you spouse watch you for irritability and anxiety." "Notify the clinic if you notice muscle twitching." "Call your primary health care provider for diarrhea." "Bake or grill your meat rather than frying it."
"Call your primary health care provider for diarrhea."
After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? "At my age, I should continue seeing the ophthalmologist as I usually do." "I will see the eye doctor when I have a vision problem and yearly after age 40." "My vision will change quickly. I should see the ophthalmologist twice a year." "Diabetes can cause blindness, so I should see the ophthalmologist yearly."
"Diabetes can cause blindness, so I should see the ophthalmologist yearly."
A nurse teaches a patient about self-monitoring of blood glucose levels. Which statement would the nurse include in this client's teaching to prevent bloodborne infections? "Wash your hands after completing each test." "Do not share your monitoring equipment." "Blot excess blood from the strip with a cotton ball." "Use gloves when monitoring your blood glucose."
"Do not share your monitoring equipment."
While assessing a client's peripheral IV site, the nurse observes a streak of red along the vein path and palpates a 1.5 inch (4-cm) venous cord. How will the nurse document this finding? "Grade 3 phlebitis at IV site" "Infection at IV site" "Thrombosed area at IV site" "Infiltration at IV site"
"Grade 3 phlebitis at IV site"
A nurse cares for a patient who is prescribed pioglitazone. After 6 months of therapy, the client reports that he has a new onset of ankle edema. What assessment question would the nurse take? "Have you gained unexpected weight this week?" "Has your urinary output declined recently?" "Have you had fever and achiness this week?" "Have you had abdominal pain recently?"
"Have you gained unexpected weight this week?"
A new nurse is caring for a client receiving drug therapy via a smart pump. What statement by the new nurse demonstrates the need for more instruction on this technology? "I don't need to manually calculate IV infusion rates with smart pumps." "Responding to IV pump alarms is a high priority for client safety." "The hospital can preprogram the pumps for high-alert druglimits." "These pumps have a system to prevent fluids from free-flowing into theclient."
"I don't need to manually calculate IV infusion rates with smart pumps."
After teaching a client who has diabetes mellitus with retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? "I have so many complications; exercising is not recommended." "I will exercise more frequently because I have so manycomplications." "I used to run for exercise; I will start training for amarathon." "I should look into swimming or water aerobics to get myexercise."
"I should look into swimming or water aerobics to get my exercise."
The nurse is instructing a patient with recurrent hyperkalemia about following a potassium-restricted diet. Which of the following patient statements indicates the need for additional instruction? a) "Bananas have a lot of potassium in them, I'll stop buying them." b) "I need to check if my cola beverage has potassium in it." c) "I will not salt my food, instead I'll use salt substitute." d) "I'll drink cranberry juice with my breakfast instead of coffee."
"I will not salt my food, instead I'll use salt substitute."
After teaching a patient with type 2 diabetes mellitus who is prescribed nateglinide, the nurse assesses the client's understanding. Which statement made by the patient indicates a correct understanding of the prescribed therapy? "I'll take this medicine during each of my meals." "I must take this medicine in the morning when I wake." "I will take this medicine before I go to bed." "I will take this medicine immediately before I eat."
"I will take this medicine immediately before I eat."
After teaching a client who is being treated for dehydration, a nurse assesses the client's understanding. Which statement indicates that the client correctly understood the teaching? "I must drink a quart (liter) of water or other liquid each day." "I will weigh myself each morning before I eat or drink." "I will use a salt substitute when making and eating my meals." d. "I will not drink liquids after 6 p.m. so I won't have to get up at night."
"I will weigh myself each morning before I eat or drink."
After teaching a client who is recovering from pancreas transplantation, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? "If I develop an infection, I should stop taking my corticosteroid." "If I have pain over the transplant site, I will call the surgeonimmediately." "I should avoid people who are ill or who have an infection." "I should take my cyclosporine exactly the way I was taught."
"If I develop an infection, I should stop taking my corticosteroid."
A client is scheduled to have a glycosylated hemoglobin (A1C) drawn and asks the nurse why she has to have it. How would the nurse respond? "It measures your average blood glucose level for the past 3 months." "It determines what type of anemia you may have." "It measures the amount of liver glycogen you have." "It determines you have some type of leukemia or other blood cancer."
"It measures your average blood glucose level for the past 3 months."
A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement would the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? "Maintain tight glycemic control and prevent hyperglycemia." "Restrict your fluid intake to no more than 2 L a day." c. "Prevent hypoglycemia by eating a bedtime snack." d. "Limit your intake of protein to prevent ketoacidosis."
"Maintain tight glycemic control and prevent hyperglycemia."
A nurse collaborates with assistive personnel (AP) to provide care for a client who is prescribed a 24-hour urine specimen collection. Which statement would the nurse include when teaching the AP about this activity? "Note the time of the client's first void and collect urine for 24 hours." "Add the preservative to the container at the end of the test." "Start the collection by saving the first urine of the morning." "It is okay if one urine sample during the 24 hours is not collected."
"Note the time of the client's first void and collect urine for 24 hours."
After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the client's understanding. Which statement made by the client indicates a need for furtherteaching? "The lower abdomen is the best location because it is closest to the pancreas." "I can reach mythigh the best, so I will use the different areas of my thighs." "By rotating the sites in one area, mychance of having a reaction is decreased." "Changing injection sites from the thigh to the arm will change absorption rates."
"The lower abdomen is the best location because it is closest to the pancreas."
A nurse delegates care to an assistive personnel (AP). Which statement will the nurse include when delegating hygiene for a client who has a vascular access device? "Provide a bed bath instead of letting the client take ashower." "Use sterile technique when changing the dressing." "Disconnect the intravenous fluid tubing prior to the client'sbath." "Use a plastic bag to cover the extremity with the device."
"Use a plastic bag to cover the extremity with the device."
A nurse teaches a client with type 1 diabetes mellitus. Which statement would the nurse include in this client's teaching to decrease the client's insulin needs? a. "Limit your fluid intake to 2 L a day." "Animal organ meat is high in insulin." "Limit your carbohydrate intake to 80 g a day." "Walk at a moderate pace for 1 mile daily."
"Walk at a moderate pace for 1 mile daily."
A nurse is teaching a client with diabetes mellitus who asks, "Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL (3.3 mmol/L)?" How would the nurse respond? "Glucose is the only fuel used by the body to produce the energy that itneeds." "Your brain needs a constant supply of glucose because it cannot storeit." "Without a minimum level of glucose, your body does not make red blood cells." "Glucose in the blood prevents the formation of lactic acid and prevents acidosis."
"Your brain needs a constant supply of glucose because it cannot storeit."
A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How would the nurse respond? "Your risk of diabetes is higher than the general population, but it may not occur." "No genetic risk is associated with the development of type 1 diabetes mellitus." "The risk for becoming a diabetic is 50% because of how it is inherited." "Female children do not inherit diabetes mellitus, but male children will."
"Your risk of diabetes is higher than the general population, but it may not occur."
A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement would the nurse include in this client's teaching to prevent injury? "Examine your feet using a mirror every day." "Rotate your insulin injection sites every week." "Check your blood glucose level before each meal." "Use a bath thermometer to test the water temperature."
"Use a bath thermometer to test the water temperature."
A nurse teaches an older woman who has a decreased production of estrogen. Which statement would the nurse include in this client's teaching to decrease injury? "Drink at least 2 quarts (2 L) of fluids each day." "Walk around the neighborhood for daily exercise." "Bathe your perineal area twice a day." "You should check your blood glucose before meals."
"Walk around the neighborhood for daily exercise."
Which of the following is considered an isotonic solution? a) 3% NaCl b) 0.9% normal saline c) 0.45% normal saline d) Dextran in NS
0.9% normal saline
A nurse is assessing clients for fluid and electrolyte imbalances. Which client will the nurse assess first for potential hyponatremia? A 34 year old who is NPO and receiving rapid intravenous D5W infusions. A 50 year old with an infection who is prescribed a sulfonamideantibiotic. A 67 year old who is experiencing pain and is prescribed ibuprofen. A 73 year old with tachycardia who is receiving digoxin.
A 34 year old who is NPO and receiving rapid intravenous D5W infusions.
A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? A 19-year-old Caucasian A 22-year-old African American A 44-year-old Asian American A 58-year-old American Indian
A 58-year-old American Indian
A nurse assesses clients at a family practice clinic for risk factors that could lead to dehydration. Which client is at greatest risk for dehydration? A 36 year old who is prescribed long-term steroid therapy. A 55 year old who recently received intravenous fluids. A 76 year old who is cognitively impaired. An 83 year old with congestive heart failure.
A 76 year old who is cognitively impaired.
A nurse is caring for a client with hypocalcemia. Which action by the nurse shows poor understanding of this condition? Assesses the client's Chvostek and Trousseau sign. Keeps the client's room quiet and dimly lit. Moves the client carefully to avoid fracturing bones. d. Administers bisphosphonates as prescribed.
Administers bisphosphonates as prescribed.
A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take? Administration of oxygen via facemask Intravenous administration of 10% glucose Implementation of seizure precautions Administration of intravenous insulin
Administration of intravenous insulin
Which of the following is the most common cause of symptomatic hypomagnesemia? a) IV drug use b) Alcoholism c) Sedentary lifestyle d) Burns
Alcoholism
A nurse is assessing clients on a medical-surgical unit. Which adult client does the nurse identify as being at greatest risk for insensible water loss? Client taking furosemide. Anxious client who has tachypnea. Client who is on fluid restrictions. Client who is constipated with abdominal pain.
Anxious client who has tachypnea.
Which of the following are the insensible mechanisms of fluid loss? a) Urination b) Nausea c) Bowel elimination d) Breathing
Breathing
The calcium level of the blood is regulated by which mechanism? a) Parathyroid hormone (PTH) b) Androgens c) Adrenal gland d) Thyroid hormone (TH)
Parathyroid hormone (PTH)
The nurse reviews the function of thyroid gland hormones. What is the primary function of calcitonin? Sodium and potassium balance Magnesium balance Norepinephrine balance Calcium and phosphorus balance
Calcium and phosphorus balance
A nurse develops a plan of care for an older client who has a fluid overload. What interventions will the nurse include in this client's care plan? (Select all that apply.) Calculate pulse pressure with each blood pressure reading. Assess skin turgor using the back of the client's hand. Assess for pitting edema in dependent body areas. Monitor trends in the client's daily weights. Assist the client to change positions frequently. Teach client and family how to read food labels for sodium.
Calculate pulse pressure with each blood pressure reading. Assess for pitting edema in dependent body areas. Monitor trends in the client's daily weights. Assist the client to change positions frequently. Teach client and family how to read food labels for sodium.
Air embolism is a potential complication of IV therapy. The nurse should be alert to which clinical manifestation associated with air embolism? a) Hypertension b) Chest pain c) Slow pulse d) Jaundice
Chest pain
A nurse prepares to insert a short peripheral venous catheter. What actions will the nurse take to use best practices? (Select all that apply.) Choose a distal site on the client's nondominant arm. Verify that the prescription is appropriate for peripheralinfusion. Place the venous catheter near an area of joint flexion. Wear a surgical mask during the catheter insertion procedure. Perform hand hygiene before inserting the catheter. Limit unsuccessful attempts by up to three clinicians to one attempt each.
Choose a distal site on the client's nondominant arm. Verify that the prescription is appropriate for peripheralinfusion. Perform hand hygiene before inserting the catheter.
A nurse is caring for a client who has a serum calcium level of 14 mg/dL (3.5 mmol/L). Which primary health care provider order does the nurse implement first? Encourage oral fluid intake. Connect the client to a cardiac monitor. Assess urinary output. Administer oral calcitonin.
Connect the client to a cardiac monitor.
A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention will the nurse implement to prevent injury while in the hospital? Ask family members to speak quietly to keep the client calm. Assess urine color, amount, and specific gravity each day. Encourage the client to drink at least 1 L of fluids each shift. Dangle the client on the bedside before ambulating.
Dangle the client on the bedside before ambulating.
A nurse is evaluating a client who is being treated for dehydration. Which assessment result does the nurse correlate with a therapeutic response to the treatment plan? Increased respiratory rate from 12 to 22 breaths/min Decreased skin turgor on the client's posterior hand and forehead Increased urine specific gravity from 1.012 to 1.030 g/mL Decreased orthostatic changes when standing
Decreased orthostatic changes when standing
The nurse assesses an older client. What age-related physiologic changes would the nurse expect? Heat intolerance Rheumatoid arthritis Dehydration Increased appetite
Dehydration
A nurse is caring for a client who has the following laboratory results: potassium 2.4 mEq/L (2.4 mmol/L), magnesium 1.8 mEq/L (0.74 mmol/L), calcium 8.5 mEq/L (2.13 mmol/L), and sodium 144 mEq/L (144 mmol/L). Which assessment does the nurse complete first? Depth of respirations Bowel sounds Grip strength Electrocardiography
Depth of respirations
A registered nurse (RN) occasionally delegates client care to licensed practical nurses (LPNs) or technicians. What information does the RN consider when delegating components of IV therapy? (Select all that apply.) Each state's Nurse Practice Act will regulate who can perform care related toIVs. The nurse would check the facility's Policies and Procedures manual. The LPN's level of experience primarily guides the decision. Technicians cannot participate in any part of caring for IV infusions. The RN remains accountable for all aspects of IV care and delegated actions. The Infusion Nurses Society has guidelines and standards of IV therapy competency.
Each state's Nurse Practice Act will regulate who can perform care related toIVs. The nurse would check the facility's Policies and Procedures manual. The RN remains accountable for all aspects of IV care and delegated actions. The Infusion Nurses Society has guidelines and standards of IV therapy competency.
Patients diagnosed with hypervolemia should avoid sweet or dry food because a) it can cause dehydration. b) it obstructs water elimination. c) it increases the patient's desire to consume fluid. d) it can lead to weight gain.
it increases the patient's desire to consume fluid.
A nurse assesses a female client who presents with hirsutism. Which question would the nurse ask when assessing this client? "How do you plan to pay for your treatments?" "How do you feel about yourself?" "What medications are you prescribed?" "What are you doing to prevent this from happening?"
"How do you feel about yourself?"
The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition? Increased rate and depth of respiration Extremity tremors followed by seizure activity Oral temperature of 102° F (38.9° C) d. Severe orthostatic hypotension
Increased rate and depth of respiration
A nurse assesses a client who was started on intraperitoneal therapy 5 days ago. The client reports abdominal pain and "feeling warm." For which complication of this therapy will the nurse assess the client? Allergic reaction Bowel obstruction Catheter lumen occlusion Infection
Infection
The nurse is assessing a client for risk of developing metabolic syndrome. Which risk factor is associated with this health condition? Hypotension Hyperthyroidism Abdominal obesity Hypoglycemia
Abdominal obesity
A nurse assesses a client who has diabetes mellitus and notes that the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the client's signs and symptoms have not changed. What action would the nurse take next? Administer another half-cup (120 mL) of orange juice. Administer a half-ampule of dextrose 50% intravenously. Administer 10 units of regular insulin subcutaneously. Administer 1 mg of glucagon intramuscularly.
Administer another half-cup (120 mL) of orange juice.
A home care nurse prepares to administer intravenous medication to a client. The nurse assesses the site and reviews the client's chart prior to administering the medication and notes it to have been inserted 4 months ago. The site has no redness, warmth, or swelling and flushes easily. What action does the nurse take? Notify the primary health care provider. Administer the prescribed medication. Discontinue the PICC. Switch the medication to the oral route.
Administer the prescribed medication.
A nurse is caring for an older client who exhibits dehydration-induced confusion. Which intervention by the nurse is best? Measure intake and output every 4 hours. Assess client further for fall risk. Increase the IV flow rate to 250 mL/hr. Place the client in a high-Fowler position.
Assess client further for fall risk.
The nurse is caring for a client who has fluid overload. What action by the nursetakes priority? Administer high-ceiling (loop) diuretics. Assess the client's lung sounds every 2 hours. Place a pressure-relieving overlay on themattress. Weigh the client daily at the same time on the same scale.
Assess the client's lung sounds every 2 hours.
A nurse is assessing a client with hypokalemia, and notes that the client's handgrip strength has diminished since the previous assessment 1 hour ago. What action does the nurse take first? Assess the client's respiratory rate, rhythm, and depth. Measure the client's pulse and blood pressure. Document findings and monitor the client. Call the health care primary health care provider.
Assess the client's respiratory rate, rhythm, and depth.
A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the client's diet would the nursedecrease? Carbohydrates Proteins Fats Total calories
Proteins
A nurse is caring for a client who has just had a central venous access line inserted. What action will the nurse take next? Begin the prescribed infusion via the new access. Ensure that an x-ray is completed to confirm placement. Check medication calculations with a second RN. Make sure that the solution is appropriate for a central line.
Ensure that an x-ray is completed to confirm placement.
A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. What action would the nurse take first? Document the finding in the client's chart. Assess tactile sensation in the client's hands. Examine the client's feet for signs of injury. Notify the primary health care provider.
Examine the client's feet for signs of injury.
A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.) Excessive thyroid-stimulating hormone—increased boneformation Excessive melanocyte-stimulating hormone—darkening of theskin Excessive parathyroid hormone—synthesis and release of corticosteroids Excessive antidiuretic hormone—increased urinary output Excessive adrenocorticotropic hormone—increased bone resorption
Excessive thyroid-stimulating hormone—increased boneformation Excessive melanocyte-stimulating hormone—darkening of theskin
After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates that the client correctly understood the teaching? Slices of smoked ham with potato salad Bowl of tomato soup with a grilled cheese sandwich Salami and cheese on whole-wheat crackers Grilled chicken breast with glazed carrots
Grilled chicken breast with glazed carrots
A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding would indicate that the medication is effective? Heart rate of 92 beats/min Respiratory rate of 18 breaths/min Oxygenation saturation of 92% Blood pressure of 144/69 mm Hg
Heart rate of 92 beats/min
A nurse cares for clients with hormone disorders. Which are common key features of hormones? (Select all that apply.) Hormones may travel long distances to get to their target tissues. Continued hormone activity requires continued production and secretion. Control of hormone activity is caused by negative feedbackmechanisms. Most hormones are stored in the target tissues for use later. Most hormones cause target tissues to change activities by changing geneactivity.
Hormones may travel long distances to get to their target tissues. Continued hormone activity requires continued production and secretion. Control of hormone activity is caused by negative feedbackmechanisms.
A client presents with anorexia, nausea and vomiting, deep bone pain, and constipation. The following are the client's laboratory values. Na + 130 mEq/L K + 4.6 mEq/L Cl - 94 mEq/L Mg ++ 2.8 mg/dL Ca ++ 13 mg/dL Which of the following alterations is consistent with the client's findings? a) Hyperkalemia b) Hyponatremia c) Hypermagnesemia d) Hypercalcemia
Hypercalcemia
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which common causes are correctly paired with the corresponding electrolyte imbalance? (Select all that apply.) Hypomagnesemia—kidney failure Hyperkalemia—salt substitutes Hyponatremia—heart failure Hypernatremia—hyperaldosteronism Hypocalcemia—diarrhea Hypokalemia—loop diuretics
Hyperkalemia—salt substitutes Hyponatremia—heart failure Hypernatremia—hyperaldosteronism Hypocalcemia—diarrhea Hypokalemia—loop diuretics
Oral intake is controlled by the thirst center, located in which of the following cerebral areas? a) Hypothalamus b) Cerebellum c) Thalamus d) Brainstem
Hypothalamus
The nurse is assessing residents at a summer picnic at the nursing facility. The nurse expresses concern due to the high heat and humidity of the day. Although the facility is offering the residents plenty of fluids for fluid maintenance, the nurse is most concerned about which? a) Lung function b) Cardiovascular compromise c) Insensible fluid loss d) Summer allergies
Insensible fluid loss
When caring for an older client who has hypothyroidism, what assessment findings will the nurse expect? (Select all that apply.) Lethargy Diarrhea Low body temperature Tachycardia Slowed speech Weight gain
Lethargy Low body temperature Slowed speech Weight gain
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a) Nausea or vomiting b) Abdominal pain or diarrhea c) Hallucinations or tinnitus d) Light-headedness or paresthesia
Light-headedness or paresthesia
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? a) Metabolic acidosis b) Respiratory alkalosis c) Metabolic alkalosis d) Respiratory acidosis
Metabolic acidosis
A 64-year-old client is brought in to the clinic with thirsty, dry, sticky mucous membranes, decreased urine output, fever, a rough tongue, and lethargy. Serum sodium level is above 145 mEq/L. Should the nurse start salt tablets when caring for this client? a) No, sodium intake should be restricted. b) No, start with the sodium chloride IV. c) Yes, this will correct the sodium deficit. d) Yes, along with the hypotonic IV.
No, sodium intake should be restricted.
A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first? a) Monitor the client's heart rhythm. b) Prepare to assist with ventilation. c) Obtain a urine specimen for drug screening. d) Prepare for gastric lavage.
Prepare to assist with ventilation.
The nurse assesses a client who is scheduled to have a laboratory test to determine if the client's adrenal glands are hypoactive. What type of testing would the client likely have? Catecholamine testing Suppression testing Bone marrow testing Provocative testing
Provocative testing
A nurse is caring for a client who is receiving an epidural infusion for pain management. Which assessment finding requires immediate intervention from the nurse? Redness at the catheter insertion site Report of headache and stiff neck Temperature of 100.1° F (37.8° C) Pain rating of 8 on a scale of 0-10
Report of headache and stiff neck
A nurse is assessing a client who has an electrolyte imbalance related to renal failure. For which potential complications of this electrolyte imbalance does the nurse assess? (Select all that apply.) Reports of palpitations Slow, shallow respirations Orthostatic hypotension Paralytic ileus Skeletal muscle weakness Tall, peaked T waves on ECG
Reports of palpitations Skeletal muscle weakness Tall, peaked T waves on ECG
Which of the following arterial blood gas results would be consistent with metabolic alkalosis? a) pH 7.26 b) Serum bicarbonate of 21 mEq/L c) pH 7.30 d) Serum bicarbonate of 28 mEq/L
Serum bicarbonate of 28 mEq/L
A nurse assesses a client who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all thatapply.) Urine output of 25 mL/hr Serum potassium level of 5.4 mEq/L (5.4 mmol/L) Urine specific gravity of 1.02 g/mL Serum sodium level of 128 mEq/L (128 mmol/L) Blood osmolality of 250 mOsm/kg (250 mmol/kg)
Serum potassium level of 5.4 mEq/L (5.4 mmol/L) Blood osmolality of 250 mOsm/kg (250 mmol/kg)
A new nurse is preparing to administer IV potassium to a client with hypokalemia. What action indicates the nurse needs to review this procedure? Notifies the pharmacy of the IV potassium order. Assesses the client's IV site every hour during infusion. Sets the IV pump to deliver 30 mEq of potassium an hour. Double-checks the IV bag against the order with the precepting nurse.
Sets the IV pump to deliver 30 mEq of potassium an hour.
A nurse assesses a client who has a radial artery catheter. Which assessment will the nurse complete first? Amount of pressure in fluid container Date of catheter tubing change Type of dressing over the site Skin color and capillary refill
Skin color and capillary refill
A nurse assesses a client's peripheral IV site, and notices edema and tenderness above the site. What action will the nurse take next? Apply cold compresses to the IV site. Elevate the extremity on a pillow. Flush the catheter with normal saline. Stop the infusion of intravenous fluids.
Stop the infusion of intravenous fluids.
and symptoms indicate that treatment is improving the client's hypokalemia? (Select all that apply.) Respiratory rate of 8 breaths/min Absent deep tendon reflexes Strong productive cough Active bowel sounds U waves present on the electrocardiogram (ECG)
Strong productive cough Active bowel sounds
A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis? a) The client has never traveled outside of the country. b) The client works in a health care insurance office. c) The client sees his physician for a check-up yearly. d) The client had a liver transplant 2 years ago.
The client had a liver transplant 2 years ago.
A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones would the nurse expect to be decreased as a result? (Select all that apply.) Thyroid-stimulating hormone Vasopressin Follicle-stimulating hormone d. Calcitonine. Growth hormone
Thyroid-stimulating hormone Follicle-stimulating hormone Growth hormone
A nurse prepares to administer a blood transfusion to a client, and checks the blood label with a second registered nurse using the International Society of Blood Transfusion (ISBT) universal bar-coding system to ensure the right blood for the right client. Which components must be present on the blood label in bar code and in eye-readable format? (Select all that apply.) Unique facility identifier Lot number related to the donor Name of the client receiving blood ABO group and Rh type of the donor Blood type of the client receiving blood Signature line for 2-person verification
Unique facility identifier Lot number related to the donor ABO group and Rh type of the donor
The nurse is planning teaching for a client who is starting exenatide extended release (ER) for diabetes mellitus type 2. Which statement will the nurse include in the teaching? "Be sure to take the drug once a day beforebreakfast." "Take the drug every evening before bedtime." c. "Give your drug injection the same day every week." d. "Take the drug with dinner at the same time each day."
c. "Give your drug injection the same day every week."
The nurse is teaching assistive personnel (AP) about hormones that are produced by the adrenal glands. Which hormone has the primary responsibility of maintaining fluid volume and electrolyte composition? a. Sodium b. Magnesium c. Aldosterone d. Renin
c. Aldosterone
A nurse reviews the laboratory test values for a client with a new diagnosis of diabetes mellitus type 2. Which A1C value would the nurse expect? a. 5.0% b. 5.7% c. 6.2% d. 7.4%
d. 7.4%
A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client? pH 7.38, HCO3 22 mEq/L (22 mmol/L), PCO2 38 mm Hg, PO2 98 mm Hg pH 7.28, HCO3 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg pH 7.48, HCO3 28 mEq/L (28 mmol/L), PCO2 38 mm Hg, PO2 98 mm pH 7.32, Hg HCO3 22 mEq/L (22 mmol/L), PCO2 58 mm Hg, PO2 88 mm Hg
pH 7.28, HCO3 18 mEq/L (18 mmol/L), PCO2 28 mm Hg, PO2 98 mm Hg
When evaluating arterial blood gases (ABGs), which value is consistent with metabolic alkalosis? a) PaCO 36 b) pH 7.48 c) HCO 21 mEq/L d) O saturation 95%
pH 7.48
Which set of arterial blood gas (ABG) results requires further investigation? a) pH 7.44, PaCO2 43 mm Hg, PaO2 99 mm Hg, and HCO3- 26 mEq/L b) pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L c) pH 7.35, PaCO2 40 mm Hg, PaO2 91 mm Hg, and HCO3- 22 mEq/L d) pH 7.38, partial pressure of arterial carbon dioxide (PaCO2) 36 mm Hg, partial pressure of arterial oxygen (PaO2) 95 mm Hg, bicarbonate (HCO3-) 24 mEq/L
pH 7.49, PaCO2 30 mm Hg, PaO2 89 mm Hg, and HCO3- 18 mEq/L
The nurse is caring for a patient diagnosed with hyperchloremia. Signs and symptoms of hyperchloremia include which of the following? Select all that apply. a) Tachypnea b) Hypotension c) Dehydration d) Lethargy e) Weakness
• Tachypnea • Weakness • Lethargy
A client is having a hysterosalpingogram. What action by the nurse is most important? Assist the client in sitting up after the procedure. Provide the client with a pad to avoid dye stains on the clothes. Teach her to take all antibiotics prescribed until finished. Inform the client that the procedure may cause shoulder pain.
Assist the client in sitting up after the procedure.
The nurse is reviewing information about FtM gender-affirming surgical options with a client. What statement by the client indicates the need for further information? "A penile implant is inserted during the phalloplasty." "Vaginal atrophy can occur and lead to itching." "I will still need cervical cancer screening if Idon't have a total hysterectomy." d. "This surgery will have many psychologic benefits for me."
"A penile implant is inserted during the phalloplasty."
A client is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best? "You do not need to worry about lymphedema since you did not have radiation therapy." "Be careful not to injure that arm or get any infection in that arm." "Numbness, tingling, and swelling are common sensations after amastectomy." "The risk for lymphedema is a real threat and can be veryself-limiting."
"Be careful not to injure that arm or get any infection in that arm."
A nurse is providing health teaching to a middle-age male-to-female (MtF) client who has undergone gender-reaffirming surgery. What information is most important to this patient? "Be sure to have an annual prostate examination." "Continue your normal health screenings." "Try to avoid being around people who are ill." "You should have an annual flu vaccination."
"Be sure to have an annual prostate examination."
A nurse provides diabetic education at a public health fair. Which disorders would thenurse include as complications of diabetes mellitus? (Select all that apply.) Stroke Kidney failure Blindness Respiratory failure Cirrhosis
Stroke Kidney failure Blindness
A 72-year-old woman is being assessed by the nurse for an annual physical. Which finding is of concern to the nurse? Thinning of pubic hair Increased size of the uterus Decreased size of the clitoris Loss of tone of the pelvic ligaments
Increased size of the uterus
A nurse teaches a client with diabetes mellitus about foot care. Which statements would the nurse include in this client's teaching? (Select all that apply.) "Do not walk around barefoot." "Soak your feet in a tub each evening." "Trim toenails straight across with a nail clipper." "Treat any blisters or sores with Epsom salts." "Wash your feet every other day."
"Do not walk around barefoot." "Trim toenails straight across with a nail clipper."
The nurse is examining a woman's breast and notes multiple small mobile lumps. Which question would be most appropriate for the nurse to ask? "When was your last mammogram at the clinic?" "How many cans of caffeinated soda do you drink in a day?" "Do the small lumps seem to change with your menstrual period?" "Do you have a first-degree relative who has breast cancer?"
"Do the small lumps seem to change with your menstrual period?"
A client is concerned about her irregular menstrual periods since she has increased her daily workouts at the gym to 2 hours each day. What is the nurses' best response? "Do you want to talk about the need for that much exercise?" "Exercise is healthy but can decrease body fat and cause irregular periods." "Bingeing and purging can cause electrolyte problems in your body." "Anorexic behavior can result in decreased estrogen levels."
"Exercise is healthy but can decrease body fat and cause irregular periods."
A client is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the client would indicate that further teaching is needed? "I am glad that these tubes will fall out at home when I finallyshower." "I should measure the drainage each day to make sure it is less than an ounce (30 mL)." "I should be careful how I lie in bed so that I will not kink the tubing." "If there is a foul odor from the drainage, I will contact my primary health care provider."
"I am glad that these tubes will fall out at home when I finallyshower."
A nurse has taught a female client about the modifiable risk factors for breast cancer. Which statement made by the client indicates that more teaching is needed? "I am fortunate that I breast-fed each of mythree children for 12 months." "It looks as though I need to start working out at the gym more often." "I am glad that we can still have wine with every evening meal." "When I have menopausal symptoms, I must avoid hormone replacement therapy."
"I am glad that we can still have wine with every evening meal."
A client is scheduled for a laparoscopy to remove endometriosis tissue. Which response by the client alerts the nurse of the need for further teaching? "The surgeon told me that carbon dioxide would be infused into my pelviccavity." "There will be one or more small incisions in order to visualize all of theorgans." "There will be some shoulder pain after the procedure that may last 48 hours." "I can return to jogging my 3-mile (5 km) routine in a fewdays."
"I can return to jogging my 3-mile (5 km) routine in a fewdays."
The nurse is reviewing discharge plans with a client who is recovering from a cervical biopsy. Which statements indicate good understanding by the client? (Select all that apply.) "I can return to work this afternoon." "I cannot carry my toddler for 2 weeks." "I cannot douche until the biopsy site is healed." "I need to wait for about 2 weeks to have intercourse." "I can use a regular tampon this evening for bleeding." "I cannot wash my perineum for 24 hours."
"I cannot carry my toddler for 2 weeks." "I cannot douche until the biopsy site is healed." "I need to wait for about 2 weeks to have intercourse."
After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a need for additional teaching? "I should increase my intake of vegetables with higher amounts of dietary fiber." "My intake of saturated fats should be no more than 10% of my total calorie intake." "I should decrease my intake of protein and eliminate carbohydrates from my diet." "My intake of water is not restricted by my treatment plan or medication regimen."
"I should decrease my intake of protein and eliminate carbohydrates from my diet."
A nurse teaches a client with diabetes mellitus about sick-day management. Which statement would the nurse include in this client's teaching? "When ill, avoid eating or drinking to reduce vomiting and diarrhea." "Monitor your blood glucose levels at least every 4 hours while sick." "If vomiting, do not use insulin or take your oral antidiabetic agent." "Try to continue your prescribed exercise regimen even if you aresick."
"Monitor your blood glucose levels at least every 4 hours while sick."
The nurse is developing a teaching plan for a client who is scheduled for her first Papanicolaou test. What instruction by the nurse is the most accurate? "The timing of the Pap smear does not matter." "Sexual intercourse will not interfere with the results." "Results can be interpreted immediately in theoffice." "Results are best if you do not douche 24 hours before the test."
"Results are best if you do not douche 24 hours before the test."
The nurse is teaching a transgender client about taking testosterone. What statement by the client indicates good understanding? "My periods should stop immediately." "Some effects can take up to a year to see." "I am glad I don't have to watch my diet." "There are very few side effects since it's a normal hormone."
"Some effects can take up to a year to see."
When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, "I will never be able to stick myself with a needle." How would the nurse respond? "I can give your injections to you while you are here in the hospital." "Everyone gets used to giving themselves injections. It really does not hurt." "Your disease will not be managed properly if you refuse to administerthe shots." "Tell me what it is about the injections that are concerning you."
"Tell me what it is about the injections that are concerning you."
The nurse is teaching a 45-year-old woman about her fibrocystic breast changes. Which statement by the client indicates a lack of understanding? "This condition will become malignant over time." "I understand that hormone-based drugs have serious adverse effects." "One cup of coffee in the morning should be enough for me." "This condition makes it more difficult to examine my breasts."
"This condition will become malignant over time."
The nurse is caring for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 7:00 a.m. (0700). At which time would the nurse assess the client for potential hypoglycemia related to the NPH insulin? 8:00 a.m. (0800) 4:00 p.m. (1600) 8:00 p.m. (2000) 11:00 p.m. (2300)
4:00 p.m. (1600)
A nurse assesses adults at a health fair. Which adults would the nurse counsel to be tested for diabetes? (Select all that apply.) A 56-year-old African-American male A 22-year-old female with a 30-lb (13.6 kg) weight gain during pregnancy A 60-year-old male with a history of liver trauma A 48-year-old female with a sedentary lifestyle A 50-year-old male with a body mass index greater than 25 kg/m2 A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg)
A 56-year-old African-American male A 48-year-old female with a sedentary lifestyle A 50-year-old male with a body mass index greater than 25 kg/m2 A 28-year-old female who gave birth to a baby weighing 9.2 lb (4.2 kg)
A nurse is reviewing the chart of a new client in the family medicine clinic and notes that the client is identified as "George Smith." The nurse enters the room and finds a woman in a skirt. What action by the nurse is best? Apologize and declare confusion about the client. Ask Mrs. Smith where her husband is right now. Ask the client about preferred forms of address. Explain that the chart must contain an error.
Ask the client about preferred forms of address.
A woman is interested in alternative and complementary treatments for the nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which therapies wound the nurse suggest? (Select all that apply.) Acupuncture Chiropractic Journaling Aromatherapy Shiatsu Black cohosh
Acupuncture Aromatherapy Shiatsu
The nurse is caring for a client who has severe hypoglycemia and is experiencing a seizure. What actions will the nurse take at this time? (Select all that apply.) Administer glucagon 1 mg subcutaneously. Be sure the bed side rails are in the up position. Notify the primary health care providerimmediately. Monitor the client's blood glucose level. Increase the intravenous infusion rate immediately.
Administer glucagon 1 mg subcutaneously. Be sure the bed side rails are in the up position. Notify the primary health care providerimmediately. Monitor the client's blood glucose level.
The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.) Age greater than 65 years Increased breast density Osteoporosis Multiparity Genetic factors Early menarche
Age greater than 65 years Increased breast density Genetic factors Early menarche
The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods would be included in the plan? (Select all that apply.) Annual mammogram Magnetic resonance imaging (MRI) Breast ultrasound Breast self-awareness Clinical breast examination Self-breast examination
Annual mammogram Breast self-awareness Clinical breast examination
A client has returned from the postanesthesia care unit after a vaginoplasty. What comfort measure does the nurse provide for this client? Apply ice to the perineum. Elevate the legs on pillows. Position the client on the left side. Raise the head of the bed.
Apply ice to the perineum.
The nurse is assessing a client for reproductive health problems. What assessments aremost important? (Select all that apply.) Bleeding Pain Sexual orientation Masses Discharge
Bleeding Pain Masses Discharge
The nurse is assessing the reproductive history of a 68-year-old postmenopausal woman. Which finding is cause for immediate action by the nurse? Vaginal dryness No Papanicolaou test for 3 years Bleeding from the vagina Leakage of urine
Bleeding from the vagina
A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which assessment findings would the nurse monitor the client? (Select all that apply.) Deep and fast respirations Decreased urine output Tachycardia Dependent pulmonary crackles Orthostatic hypotension
Deep and fast respirations Tachycardia Orthostatic hypotension
During dressing changes, the nurse assesses a client who had breast reconstruction. Which finding would cause the nurse to take immediate action? Slightly reddened incisional area Blood pressure of 128/75 mm Hg Temperature of 99° F (37.2° C) Dusky color of the breast flap
Dusky color of the breast flap
The nurse is working with a male client who has gynecomastia. What action by the nurseis most appropriate? Teach the client to perform self-breast examination. Review the plan for chemotherapy after surgery. Educate him on the side effects of tamoxifen. Assess his usual daily alcohol intake.
Educate him on the side effects of tamoxifen.
A woman diagnosed with breast cancer had these laboratorytests performed at an office visit: Alkaline phosphatase 125 U/L (2.2 mckat/L) Total calcium 12 mg/dL (3 mmol/L) Hematocrit 39% (0.39) Hemoglobin 14 g/dL (140 mmol/L) Which test results indicate to the nurse that some further diagnostics are needed? Elevated alkaline phosphatase and calcium suggests bone involvement. Only alkaline phosphatase is decreased, suggesting liver metastasis. Hematocrit and hemoglobin are decreased, indicating anemia. The elevated hematocrit and hemoglobin indicate dehydration.
Elevated alkaline phosphatase and calcium suggests bone involvement.
The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time? Assess the client's blood glucose level. Monitor the client's urinary output every hour. Establish intravenous access to provide fluids. Give regular insulin per agency policy.
Establish intravenous access to provide fluids.
A nurse is learning about the health care needs of individuals who identify as LGBTQIA+ and transgender. Which terms are correctly defined? (Select all that apply.) Gender dysphoria—distress caused by incongruence between natal sex and gender identity. Gender identity—a person's inner sense of being a male, a female, or an alternative gender. Natal sex—the sex one is born with or is assigned to at birth. Transgender—a person who dresses in the clothing of the opposite sex. Trans-woman—a male who identified or lives as a woman.
Gender dysphoria—distress caused by incongruence between natal sex and gender identity. Gender identity—a person's inner sense of being a male, a female, or an alternative gender. Natal sex—the sex one is born with or is assigned to at birth. Trans-woman—a male who identified or lives as a woman.
A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen:• Fasting blood glucose: 75 mg/dL (4.2 mmol/L)• Postprandial blood glucose: 200 mg/dL (11.1 mmol/L) • Hemoglobin A1C level: 5.5% How would the nurse interpret these laboratory findings? Increased risk for developing ketoacidosis Good control of blood glucose Increased risk for developing hyperglycemia Signs of insulin resistance
Good control of blood glucose
The nurse is caring for a newly admitted older adult who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect? Diabetic ketoacidosis (DKA) Severe hypoglycemia Chronic kidney disease (CKD) Hyperglycemic-hyperosmolar state (HHS)
Hyperglycemic-hyperosmolar state (HHS)
A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: What action would the nurse take? Administer the potassium and then consult with the primary health care provider about the fluid prescription. Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription. Administer the potassium first before increasing the infusion flow rate for the client. Increase the intravenous flow rate before administering the potassium to the client.
Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription.
A client had a vaginoplasty under epidural anesthetic. Which action by the nurse is most important? Ensure that the urinary catheter is securely attached to the leg. Instruct the client not to try to get out of bed unassisted. Monitor the patient's dressings and wound drainage. Position the Jackson-Pratt drain to the contralateral side.
Instruct the client not to try to get out of bed unassisted.
A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. What action would the nurse take? Apply ice to the site to reduce inflammation. Consult the provider for a new administration route. Assess the client for other signs of cellulitis. Instruct the client to rotate sites for insulin injection.
Instruct the client to rotate sites for insulin injection.
A client is starting hormonal therapy with tamoxifen to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? It blocks the release of luteinizing hormone. It interferes with cancer cell division. It selectively blocks estrogen in the breast. It inhibits DNA synthesis in rapidly dividing cells.
It selectively blocks estrogen in the breast.
A nurse works with many transgender patients. What routine monitoring is important for the nurse to facilitate in this population? (Select all that apply.) Lipid profile Liver function tests Mammograms if breast tissue is present Prostate-specific antigen (PSA) for natal males Renal profile Cervical cancer screening
Lipid profile Liver function tests Mammograms if breast tissue is present Prostate-specific antigen (PSA) for natal males Cervical cancer screening
The nurse is caring for a client who has diabetes mellitus type 1 and is experiencing hypoglycemia. Which assessment findings will the nurse expect? (Select all that apply.) Warm, dry skin Nervousness Rapid deep respirations Dehydration Ketoacidosis Blurred vision
Nervousness Blurred vision
The mother of an 18-year-old girl asks the nurse which screening her daughter would receive now based on evidence-based recommendations. Which suggestion by the nurse is best? Papanicolaou test Human papilloma virus (HPV) test Mammogram No screenings at this time
No screenings at this time
Which finding in a female client by the nurse would receive the highest priority for further diagnostics? Tender moveable masses throughout the breast tissue Nipple discharge without a palpable mass Nontender fixed mass in the upper outer quadrant of the breast Small, painful mass under warm reddened skin and nipple discharge
Nontender fixed mass in the upper outer quadrant of the breast
A transgender client taking spironolactone is in the internal medicine clinic reporting heart palpitations. What action by the nurse takes priority? Draw blood to test serum potassium. Have the client lie down and rest. Obtain a STAT electrocardiogram (ECG). Take a set of vital signs.
Obtain a STAT electrocardiogram (ECG).
A younger woman from an unfamiliar culture is at high risk for breast cancer and is considering a prophylactic mastectomy and oophorectomy. What action by the nurse is most appropriate? Discourage this surgery since the woman is still of childbearing age. Reassure the client that reconstructive surgeryis as easy as breast augmentation. Inform the client that this surgery removes all mammary tissue and cancer risk. Offer to include support people, such as the male partner, in the decisionmaking.
Offer to include support people, such as the male partner, in the decisionmaking.
After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the client's electronic medical record? (Select all that apply.) Peau d'orange Dense breast tissue Nipple retraction Mobile mass at 2 o'clock Nontender axillary nodes Skin ulceration
Peau d'orange Nipple retraction Mobile mass at 2 o'clock Skin ulceration
A 67-year-old male client had serum laboratory tests performed during his annual examination. The nurse reviews his results, as follows: testosterone: 680 ng/dL (23.6 nmol/L); prostate-specific antigen: 10 ng/mL (10 mcg/L); prolactin: 5 ng/mL (217.4 pmol). What action by the nurse is best? Assess for possible galactorrhea with breast discharge. Note the possibility of a testicular tumor. Communicate that results were normal. Prepare the client for further diagnostic testing.
Prepare the client for further diagnostic testing.
A transgender client is taking transdermal estrogen. What assessment finding does the nurse report immediately to the primary health care provider? Breast tenderness Headaches Red, swollen calf Swollen ankles
Red, swollen calf
A client is preparing for MtF gender-affirming surgery. The client is worried about the voice not sounding feminine enough. What action by the nurse is best? Ask if the client has considered vocal cord surgery to change the voice. Refer the client for vocal therapy with a speech-language pathologist. Teach the client that there will be no effect on the patient's voice. Tell the client that the use of hormones will eventually change the voice.
Refer the client for vocal therapy with a speech-language pathologist.
A nurse collaborates with the interprofessional team to develop a plan of care for a client who is newly diagnosed with diabetes mellitus. Which team members would the nurse include in this interprofessional team meeting? (Select all that apply.) Registered dietitian nutritionist Clinical pharmacist Occupational therapist Primary health care provider Speech-language pathologist
Registered dietitian nutritionist Clinical pharmacist Primary health care provider
A client is placed on a medical regimen of doxorubicin (Adriamycin), cyclophosphamide, and fluorouracil for breast cancer. Which side effect seen in the client would the nurse report to the primary health care provider immediately? Shortness of breath Nausea and vomiting Hair loss Mucositis
Shortness of breath
The nurse is reviewing discharge instructions with a client who has just experienced an endometrial biopsy. Which finding would be reported to the primary health care provider immediately? Mild cramping Slight chills and fever Spotting of blood Fatigue after anesthesia
Slight chills and fever
A client has just returned from a right radical mastectomy. Which action by the assistive personnel (AP) would require the nurse consider to intervene? Checking the amount of urine in the catheter collection bag Elevating the right arm on a pillow Taking the blood pressure on the right arm Encouraging the client to squeeze a rolled washcloth
Taking the blood pressure on the right arm
The nurse is reviewing possible complications from a phalloplasty. What factors does the nurse include? (Select all that apply.) Wound infections Urethral complications Rectal injury Bleeding Donor site scarring Recurrent urinary tract infections
Wound infections Urethral complications Rectal injury Bleeding Donor site scarring
A nurse is caring for clients with electrolyte imbalances on a medical-surgical unit. Which clinical signs and symptoms are correctly paired with the contributing electrolyte imbalance? (Select all that apply.) Hypokalemia—muscle weakness with respiratory depression Hypermagnesemia—bradycardia and hypotension Hyponatremia—decreased level of consciousness Hypercalcemia—positive Trousseau and Chvostek signs Hypomagnesemia—hyperactive deep tendon reflexes Hypernatremia—weak peripheral pulses
Hypokalemia—muscle weakness with respiratory depression Hypermagnesemia—bradycardia and hypotension Hyponatremia—decreased level of consciousness Hypomagnesemia—hyperactive deep tendon reflexes Hypernatremia—weak peripheral pulses
A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately? Serum chloride level of 98 mEq/L (98 mmol/L) Serum calcium level of 8.8 mg/dL (2.2 mmol/L) Serum sodium level of 132 mEq (132 mmol/L) Serum potassium level of 2.5 mEq/L (2.5 mmol/L)
Serum potassium level of 2.5 mEq/L (2.5 mmol/L)
