ATI NCLEX Challenge 7

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority?

Monitor the client for hypoglycemia

A nurse is assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these finding with which of the following types of urinary incontinence?

Overflow incontinence

A nurse is caring for a client who is being admitted to the medical-surgical unit from the emergency department. The nurse is reviewing the client's medical records. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Potential complication: Type 1 diabetes mellitus Actions to take: - Teach the client about the signs of hyperglycemia -Assess the client's feet for sensation Parameters to monitor: -Fingerstick blood glucose - Urinary output

A nurse in the emergency department is caring for an older adult client. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Potential condition: - Urinary tract infection Actions to take: - Obtain a prescription for an antibiotic - Obtain a urine sample Parameters to monitor: - Urine color - Temperature

A nurse is reviewing the medication list for a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize which of the following medications can cause glucose intolerance?

Prednisone

A nurse is talking with a client who is scheduled to repair retinal detachment. Which of the following preoperative instructions should the nurse include?

Restrict head movement

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?

Sudden pain relief

A nurse at an outpatient surgery center is providing discharge teaching to a client and his spouse following surgical removal of a cataract. Which of the following should the nurse include in the teaching?

The client should wear dark glasses while outdoors.

A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?

The medication should be applied on a regular schedule for the rest of the client's life.

A nurse is providing teaching to a client about measures to prevent urinary tract infections (UTIs). Which of the following client statements indicates a need for further teaching?

"I will need to wipe my perineal area from back to front after urination"

A nurse is providing postoperative teaching to a client who is scheduled for cataract surgery. Which of the following information should the nurse include?

"Vision will be greatly improved on the day of surgery"

A nurse is teaching a client who has a urinary tract infection (UTI) and is taking ciprofloxacin. Which of the following instructions should the nurse give to the client?

"You should report any tendon discomfort you experience while taking this medication"

A client who has type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make?

"Your bod has insulin resistance and decreased insulin secretion"

A nurse is admitting a client who has type 1 diabetes mellitus. Select the 7 findings that require immediate attention.

- Bicarbonate level - Sodium level - Blood pressure - Client self-monitoring of blood glucose - IV access - Glasgow coma scale - ECG findings

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (select all that apply)

- Blurred vision - Tachycardia -Moist, clammy skin

A nurse is preparing to administer 10 units of regular insulin and 20 units of NPH insulin to a client. What is the sequence of events the nurse should follow? (Move the steps of mixing insulin on the left into the box on the right, placing them in the selected order of performance. All steps must be used.)

- Inspect vials for contaminants - Roll NPH vial between palms of hands - Inject air into NPH insulin vial -Inject air into regular insulin vial -Withdraw short-acting insulin into syringe - Add intermediate insulin to syringe

A nurse is preparing a teaching session about reducing the risk of complications of diabetes mellitus. Which of the following information should the nurse plan to include in the teaching? (Select all that apply).

- Reduce cholesterol and saturate fat intake - Increase physical activity and daily exercise - Enroll in a smoking-cessation program - Maintain optimal blood pressure to prevent kidney damage

A nurse is admitting a client who has type 1 diabetes mellitus. Check the 7 findings that require immediate attention.

- bicarbonate level - sodium level - client self-monitoring of blood glucose - IV access - Blood pressure results - Glasgow coma scale score - ECG findings

A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply).

-"Your provider might prescribe anticholinergic medications" - "You should limit fluids in the evening" - "You should restrict your intake of caffeine"

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

0.9% sodium chloride IV bolus

A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?

0745

A nurse is caring for a client who has diabetes and a new prescription for units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?

42 units

A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. Which of the following glycosylated hemoglobin (HbA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?

6.3%

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Acetone odor to breath

A nurse is teaching a client who has diabetes mellitus and a new prescription for glimepiride. The nurse should teach the client to avoid which of the following drinks while taking this medication?

Alcohol

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

Apply moist barrier ointment to the client's skin

A nurse is caring for a client who is receiving mydriatic eye drops. Which of the following manifestations indicates to the nurse that the client has developed a systemic anticholinergic effect?

Constipation

A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client?

Cystitis

A nurse is planning care for a client who has urolithiasis. Which of the following actions should the nurse take?

Encourage intake of at least 3 L of fluids per day

A nurse is teaching a client who has diabetes mellitus and receives 25 units of NPH insulin every morning if her blood glucose level is above 200 mg/dL. Which of the following information should the nurse include?

Expect the NPH insulin to peak in 6 to 14 hr.

A nurse is caring for a client who has a new diagnosis of urolithiasis. Which of the following should the nurse identify as an associated risk factor?

Family history

A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus?

Fasting blood glucose 155 mg/dL

A nurse is preparing to administer lispro insulin to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take?

Inject the insulin 15 min before a meal

A nurse is planning care for a client who has cystitis. Which of the following interventions should the nurse include in the plan?

Instruct the client to avoid drinking carbonated beverages.

A nurse is providing teaching for a client who has diabetes and a new prescription for insulin glargine. Which of the following instructions should the nurse provide regarding this type of insulin?

Insulin glargine has a duration of 18 to 24 hr.

A nurse is teaching a client who has a new prescription for regular insulin and NPH insulin. Which of the following instructions should the nurse include in the teaching?

Keep the open vial of insulin at room temperature

A nurse is teaching a client who is taking metformin XR for type II diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

"Take the medication with a meal"

A nurse is teaching a client how to draw up regular insulin and NPH insulin into the same syringe. Which of the following instructions should the nurse include?

Discard regular insulin that appears cloudy

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching?

"I give the insulin injections in my abdominal area"

A nurse is providing teaching for a client who is newly diagnosed with type 2 diabetes mellitus and has a prescription for glipizide. Which of the following statements by the nurse best describes the action of glipizide?

"Glipizide stimulates your pancreas to release insulin"

A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?

"I will clean the hearing aids with alcohol wipes"

A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus about self-administration of insulin. Which of the following instructions should the nurse include?

"Store the current bottle of insulin at room temperature"

A nurse is teaching a client who has type 1 diabetes mellitus about foot care. Which of the following statements by the client indicates an understanding of the teaching?

"I'll check my feet every day for sores and bruises"

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

"Maintain stable blood glucose levels"

A nurse is caring for the client who has Meniere disease and asks if he is allowed to ambulate independently. Which of the following responses should the nurse make?

"Please ring for assistance when you wish to get out of bed"

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi?

Dehydration

A nurse is caring for a client who has bilateral eye patches in place following an injury. When the client's food tray arrives, which of the following interventions should the nurse take to promote independence in eating?

Describe to the client the location of the food on the tray

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?

Determine if the client uses hearing aids

A nurse is reviewing the medical record of a client who has urinary tract infection (UTI). Which of the following findings should the nurse recognize as a risk factor?

Diabetes mellitus

A nurse is caring for a client who has diabetes and plan to administer his regular insulin subcutaneously before he eats breakfast at 0800. After checking the client's morning glucose level, which of the following actions should the nurse take?

Give the insulin at 0730

A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following?

Graham crackers

A nurse in a clinic is assessing a client who has a new diagnosis of interstitial cystitis. The nurse should expect which of the following findings?

Negative urine culture

A nurse is performing a monofilament sensory assessment of a client who has diabetes mellitus. When performing this assessment, for which of the following complications is the nurse monitoring?

Neuropathy

A nurse is caring for a client who has type 1 diabetes mellitus. Which of the following recommendations should the nurse make to the client for a sweetener?

Nonnutritive sugar substitute

A nurse notes a provider frequently arrives to the unit with bloodshot eyes and smells like alcohol after lunch. Which of the following actions should the nurse take?

Notify the nursing supervisor of the concerns.

A nurse is caring for a client who is postoperative following a left corneal transplant. The nurse observes purulent drainage from the affected eye. Which of the following actions is the nurse's priority?

Notify the surgeon

A nurse is planning care for a client who has detached retina and is preoperative for a surgical repair. The nurse should prepare to administer which of the following medications?

Phenylephrine

A nurse is admitting an older adult client who has diabetic neuropathy with painful, burning feet. Which of the following interventions should the nurse anticipate the health care provider to prescribe?

Place a bed cradle on the client's bed.

A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetic ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?

Regular insulin

A nurse is assessing a client who has an acoustic neuroma. Which of the following client manifestations should the nurse expect?

Vetigo