CHA Final Exam

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? 1. Sustained tissue damage 2. Requires nasogastric suction 3. Has a history of Addison's disease 4. Uric acid level of 9.4 mg/dL

2. Requires nasogastric suction

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin pump" 2. "I need to increase my fluid intake" 3. "I need to monitor my blood glucose every 3-4 hours" 4. "I need to call the HCP because of these symptoms"

1. "I need to stop my insulin pump" When a client with DM is unable to eat normally because of an illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the HCP. The client should monitor the blood glucose level every 3-4 hours. The client should also monitor the urine for ketones during illness.

The nurse is assigned to care for a group of clients. On review of the client's medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? 1. A client with an ileostomy 2. A client with heart failure 3. A client on long-term corticosteroid therapy 4. A client receiving frequent wound irrigation

1. A client with an ileostomy

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 180-200 mg/dL. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? 1. Prednisone 2. Atenolol 3. Phenelzine 4. Allopurinol

1. Prednisone Prednisone may decrease the effect of oral hypoglycemics, insulin, diuretics, and potassium supplements. Option 2, a beta blocker, and option 3, an MAOI, 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 nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? (select all that apply) 1. Activities should be resumed gradually 2. Avoid contact with other individuals, except family members, for at least 6 months 3. A sputum culture is needed every 2-4 weeks once medication therapy is initiated 4. Respiratory isolation is not necessary because family members already have been exposed 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags 6. When 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment

1. Activities should be resumed gradually 3. A sputum culture is needed every 2-4 weeks once medication therapy is initiated 4. Respiratory isolation is not necessary because family members already have been exposed 5. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags The nurse should provide the client and family with information about TB and allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2-3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activities should be resumed gradually and a well-balanced diet that is rich in iron, protein and vitamin c to promote healing and prevent recurrence of infections should be consumed. Respiratory isolation is not necessary b/c family members already have been exposed. Instruct the client about thorough hand washing, to cover the mouth and nose when coughing or sneezing, and to put used tissues into plastic bags. A sputum culture is needed every 2-4 weeks once medication therapy is initiated. When the results of 3 sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment

A client has begun therapy with theophylline. The nurse should plan to teach the client to limit the intake of which items while taking this medication? 1. Coffee, cola, and chocolate 2. Oysters, lobster, and shrimp 3. Melons, oranges, and pineapple 4. Cottage cheese, cream cheese, and dairy creamers

1. Coffee, cola, and chocolate Theophylline is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola and chocolate

The home health care nurse is visiting a client who was recently diagnosed with type 2 DM. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? (select all that apply) 1. Diarrhea may occur secondary to the metformin 2. The repaglinide is not taken if a meal is skipped 3. The repaglinide is taken 30 minutes before eating 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes 5. Muscle pain is an expected effect of metformin and may be treated with acetaminophen 6. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide

1. Diarrhea may occur secondary to the metformin 2. The repaglinide is not taken if a meal is skipped 3. The repaglinide is taken 30 minutes before eating 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes Repaglinide, a rapid-acting oral hypoglycemic agent that stimulates pancreatic insulin secretion, should be taken before meals (approx. 30 min before meals) and should be withheld if the client does not eat. Hypoglycemia is a side effect of repaglinide and the client should always be prepared by carrying a simple sugar at all times. metformin is an oral hypoglycemic give in combination with repaglinide and works by decreasing hepatic glucose production. A common side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin but it might signify a more serious condition that warrants health care provider notification, not the use of acetaminophen

The community health nurse is conducting an educational session with community members regarding the s/s associated with TB. The nurse informs the participants that TB is considered as a diagnosis if which signs and symptoms are present? (select all that apply) 1. Dyspnea 2. Headache 3. Night sweats 4. A blood, productive cough 5. A cough with the expectoration of mucoid sputum

1. Dyspnea 3. Night sweats 4. A blood, productive cough 5. A cough with the expectoration of mucoid sputum TB should be considered for any clients with a persistent cough, weight loss, anorexia, night sweats, hemoptysis, shortness of breath, fever or chills. The client's previous exposure to TB should also be assessed and correlated with the clinical manifestations

The nurse is creating a plan of care for the client with multiple myeloma and includes which priority intervention in the plan? 1. Encouraging fluids 2. Providing frequent oral care 3. Coughing and deep breathing 4. Monitoring the red blood cell count

1. Encouraging fluids Hypercalcemia caused by bone destruction is a priority concern in the client with multiple myeloma. The nurse should administer fluids in adequate amounts to maintain a UO of 1.5-2L/day; this requires about 3 L of fluid intake per day. The fluid is needed not only to dilute the calcium overload but also to prevent protein from precipitating in the renal tubules. Options 2-4 may be components of the plan of care but are not priority.

The nurse is caring for a client with lung cancer and bone metastasis. What signs and symptoms would the nurse recognize as indications of a possible oncological emergency? (select all that apply) 1. Facial edema in the morning 2. Weight loss of 20 lbs (9 kgs) in 1 month 3. Serum calcium level of 12 mg/dL 4. Serum sodium level of 136 mg/dL 5. Serum potassium level of 3.4 mg/dL 6. Numbness and tingling of the lower extremities

1. Facial edema in the morning 3. Serum calcium level of 12 mg/dL 6. Numbness and tingling of the lower extremities Oncological emergencies include sepsis, disseminated intravascular coagulation, syndrome of inappropriate antidiuretic hormone, spinal cord compression, hypercalcemia, superior vena cava syndrome, and tumor lysis syndrome. Blockage of blood flow to the venous system of the head resulting in facial edema is a sign of superior vena cava syndrome. A serum calcium level of 12 mg/dL indicates hypercalcemia. Numbness and tingling of the lower extremities could be a sign of spinal cord compression. Mild hypokalemia and weight loss are not oncological emergencies. A sodium level of 136 mg/dL is a normal level

The HCP prescribed exenatide for a client with type 1 DM who takes insulin. The nurse should plan to take which most appropriate intervention? 1. Withhold the medication and call the HCP, questioning the prescription for the client 2. Administer the medication within 60 minutes before the morning and evening meal 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. Withhold the medication and call the HCP, questioning the prescription for the client Exentaide is an incretin mimetic used for type 2 DM only. It is not recommended for clients taking insulin. Hence, the nurse should withhold the medication and question the HCP 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 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 dinner time 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. Hypoglycemia may be experienced before dinner time 3. The insulin should be administered at room temperature Humulin NPH is an intermediate-acting insulin. The onset of action is 60-120 minutes, it peaks in 6-14 hours, and its duration of action is 16-24 hours. Regular insulin is a short-acting insulin. Depending on the type, the onset of action is 30-60 minutes, it peaks in 1-5 hours, and its duration is 6-10 hours. Hypoglylcemic 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.

A nurse is reviewing the laboratory test results of a client with renal disease. Which of the following would the nurse expect to find? 1. Increased calcium level 2. Increased white blood cells 3. Decreased blood urea nitrogen level 4. Decreased # of plasma cells in bone marrow

1. Increased calcium level Findings indicative of multiple myeloma are an increased number of plasma cells in the bone marrow, anemia, hypercalcemia caused by the release of calcium from the deteriorating bone tissue and an elevated BUN level.

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. Which 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. Initiate an infusion of 3% NaCl 3. Restrict fluids to 800 mL over 24 hours 5. Administer a vasopressin antagonist as prescribed 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 hyponatremia is severe, less than 120 mEg/L. An IV infusion of 3% saline is hypertonic. Hypertonic saline must be infused slowly as prescribed and an infusion pump must be used. Fluid restriction is a useful strategy aimed at correcting dilutional hyponatremia. Vasopressin is an ADH; vasopressin antagnoists are used to treat SIADH. Maximizing venous return helps to avoid stimulating stretch receptors in the heart that signal the pituitary that more ADH is needed.

The nurse reviews a client's laboratory report and notes that the client's serum phosphorus (phosphate) level is 1.8mg/dL. Which condition most likely caused this serum phosphorus level? 1. Malnutrition 2. Renal insufficiency 3. Hypoparathyroidism 4. Tumor lysis syndrome

1. Malnutrition

The nurse notes that a client's arterial blood gas results reveal: pH: 7.50 PaCO2: 30 mmHg The nurse monitors the client for which clinical manifestations associated with these ABG results? (select all that apply) 1. Nausea 2. Confusion 3. Bradypnea 4. Tachycardia 5. Hyperkalemia 6. Lightheadedness

1. Nausea 2. Confusion 4. Tachycardia 6. Lightheadedness

Potassium chloride IV is prescribed for a client with hypokalemia. Which actions should the nurse take to plan for preparation and administration of the potassium? (select all that apply) 1. Obtain an IV infusion pump 2. Monitor urine output during administration 3. Prepare the medication for bolus administration 4. Monitor the IV site for s/s of infiltration or phlebitis 5. Ensure that the medication is diluted in the appropriate volume of fluid 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution

1. Obtain an IV infusion pump 2. Monitor urine output during administration 4. Monitor the IV site for s/s of infiltration or phlebitis 5. Ensure that the medication is diluted in the appropriate volume of fluid 6. Ensure that the bag is labeled so that it reads the volume of potassium in the solution

The nurse is conducting a history and monitoring laboratory values on a client with multiple myeloma. What assessment findings should the nurse expect to note? (select all that apply) 1. Pathological fracture 2. Urinalysis positive for nitrites 3. Hemoglobin level of 15.5 g/dL 4. Calcium level of 8.6 mg/dL 5. Serum creatinine level of 2.0 mg/dL

1. Pathological fracture 2. Urinalysis positive for nitrites 5. Serum creatinine level of 2.0 mg/dL Multiple myeloma is a B-cell neoplastic condition characterized by abnormal malignant proliferation of plasma cells and the accumulation of mature plasma cells in the bone marrow. The client with malignant melanoma may experience pathologic fractures, hypercalcemia, anemia, recurrent infections, and renal failure. A serum calcium level of 8.6 mg/dL and a hgb level of 15.5 g/dL are normal values Therefore, the correct answers are pathological fractures, positive UA for nitrites and a a serum creatinine level of 2.0 mg/dL

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L. The nurse reports the serum sodium level to the HCP and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? (Select all that apply) 1. Peas 2. Nuts 3. Cheese 4. Cauliflower 5. Processed oat cereals

1. Peas 2. Nuts 4. Cauliflower

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which s/s, if 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 RR

1. Polyuria Chronic hyperglycemia, resulting from poor glycemic control, contributes to the microvascular and macrovascular complications of DM. Classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Diaphoresis may occur in hypoglycemia. Hypoglycemia is an acute complication of DM; however, it does not predispose a client to the chronic complications of DM. Therefore, option 2 can be eliminated because this finding is characteristic of hypoglycemia. Options 3 & 4 are not associated with diabetes mellitus

The nurse reviews the blood gas results of a client with atelectasis. The nurse analyzes the results and determines that the client is experiencing respiratory acidosis. Which result validates the nurse's findings? 1. pH 7.25.....PaCO2 50 mmHg 2. pH 7.35.....PaCO2 40 mmHg 3. pH 7.50.....PaCO2 52 mmHg 4. pH 7.52......PaCO2 28 mmHg

1. pH 7.25.....PaCO2 50 mmHg

A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the health care provider will request which prescriptions? (select all that apply) 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone

1. Radiation 2. Chemotherapy 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone Cancer is a common cause of SIADH. In SIADH, excessive amounts of water are reabsorbed by the kidney and put into the systemic circulation. The increased water causes hyponatremia (decreased serum sodium levels) and some degree of fluid retention. The syndrome is managed by treating the condition and cause and usually includes fluid restriction, increased sodium intake, and medication with a MOA that is antagonistic to antidiuretic hormone. Sodium levels are monitored closely because hypernatremia can develop suddenly as a result of treatment. The immediate institution of appropriate cancer therapy, usually radiation or chemotherapy, can cause tumor regression so that antidiuretic hormone synthesis and release processes return to normal

The nurse is caring for a client with several broken ribs. The client is most likely to experience what type of acid-base imbalance? 1. Respiratory acidosis from inadequate ventilation 2. Respiratory alkalosis from anxiety and hyperventilation 3. Metabolic acidosis from calcium loss d/t broken bones 4. Metabolic alkalosis from taking analgesics containing base products

1. Respiratory acidosis from inadequate ventilation

A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assess for other signs of which condition? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome

1. Right pneumothorax Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi

Which client is at risk for the development of a sodium level at 130mEq/L? 1. The client who is taking diuretics 2. The client with hyperaldosteronism 3. The client with Cushing's syndrome 4. The client who is taking corticosteroids

1. The client who is taking diuretics

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? 1. The client's pain rating 2. Nonverbal cues from the client 3. The nurse's impression of the client's pain 4. Pain relief after appropriate nursing intervention

1. The client's pain rating The client's self-report is a critical component of the pain assessment. The nurse should ask the client to describe the pain and listen carefully to the words the client uses to describe the pain. Nonverbal cues from the client are important but are not the most appropriate pain assessment measure. The nurses's impression of the client's pain is not appropriate in determining the client's level of pain. Assessing pain relief is an important measure, but this option is not related to the subject of the question

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. Tremors 3. Irritability 4. Nervousness 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 & 6 are unrelated to the manifestations of hypoglycemia. In hypoglycemia, usually the client feels hunger

The nurse is assessing a client with suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? 1. Twitching 2. Hypoactive bowel sounds 3. Negative Trousseau's sign 4. Hypoactive deep tendon reflex

1. Twitching

The nurse reviews a client's electrolyte laboratory report and notes that the potassium level is 2.5 mEq/L. Which patterns should the nurse watch for on the ECG as a result of the laboratory value? (select all that apply) 1. U waves 2. Absent P waves 3. Inverted T waves 4. Depressed ST segment 5. Widened QRS complex

1. U waves 3. Inverted T waves 4. Depressed ST segment

The nurse is caring for a client who has been receiving IV diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? 1. Weight loss and poor skin turgor 2. Lung congestion and increased HR 3. Decreased hematocrit and increased urine output 4. Increased RR and increased BP

1. Weight loss and poor skin turgor

The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates a 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 amount of air equal to the desired dose of insulin into each vial

1. Withdraws the NPH insulin first 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, 4 identify correct actions for preparing NPH and short-acting insulin

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 now and then" 2. "I need to constantly watch for s/s of low blood sugar" 3. "I need to let my HCP know if I get unusually tired" 4. "I will be sure to not drink alcohol excessively while on this medication"

2. "I need to constantly watch for s/s of low blood sugar" Metformin is classified as a biguanide and is the most commonly used medication for type 2 DM 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 sugar 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 s/s occur, the client should inform the HCP 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 teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate an understanding of the teaching? (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 medication is working" 4. "I need to follow a low-fat diet to avoid pancreatitis when taking this medication" 5. "I should report headache and drowsiness to my HCP since these symptoms could be related to my desmopressin"

2. "I should decrease my oral fluids when I start this medication" 5. "I should report headache and drowsiness to my HCP since these symptoms could be related to my desmopressin" In diabetes insipidus, there is a deficiency in antidiuretic hormone (ADH), resulting in large urinary losses. Desmopressin is an analog of ADH. 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 HCP. The amount of urine should decreased, not increased, when desmopressin is started. Desmopressin does not cause pancreatitis

The nurse is providing instructions to the client newly diagnosed with diabetes mellitus who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching? 1. "Inject the pramlintide at the same time you take your other medications" 2. "Take you prescribed pills 1 hour before or 2 hours after the injection" 3. "Be sure to take the pramlintide with food so you don't upset your stomach" 4. "Make sure you take your pramlintide immediately after you eat so you don't experience a low blood sugar"

2. "Take you prescribed pills 1 hour before or 2 hours after the injection" Pramlintide is used for clients with types 1 and 2 DM who use insulin. It is administered subq before meals to lower blood glucose level after meals, leading to less fluctuation during the day and better long-term glucose control. Because pramlintide delays gastric emptying, oral medications should be given 1 hour before or 2 hours after an injection of pramlintide; therefore, instructing the client to take his or her pills 1 hour before or 2 hours after the injection is correct. Pramlintide should not be taken at the same time as other medications. Pramlintide is given immediately before the meal in order to control postprandial rise in blood glucose, not necessarily to prevent stomach upset. It is incorrect to instruct the client to take the medication after eating, as it will not achieve its full therapeutic effect.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1. A low RR 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury

2. Diminished breath sounds This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? 1. "I should not exercise since I am taking insulin" 2. "The best time for me to exercise is after breakfast" 3. "The best time for me to exercise is mid- to late afternoon" 4. "NPH is a basal insulin, so I should exercise in the evening"

2. "The best time for me to exercise is after breakfast" Exercise is an important part of diabetes management. It promotes weight loss, decreases insulin resistance, and helps to control blood glucose levels. A hypoglycemic reaction may occur in response to increased exercise, so clients should exercise either an hour after mealtime or after consuming a 10-15 gram carbohydrate snack, and they should check their blood glucose level before exercising Option 1 is incorrect because clients with diabetes should exercise, though they should check with their HCP before starting a new exercise program. Option 3 is incorrect; clients should avoid exercise during the peak time of insulin. NPH peaks at 4-12 hours; therefore, afternoon exercise takes place during the peak of the medication. Option 4 is incorrect; NPH insulin is an intermediate-acting insulin, not a basal insulin

The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? 1. 5 seconds 2. 10 seconds 3. 30 seconds 4. 60 seconds

2. 10 seconds Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? (Select all that apply) 1. A low arterial PCo2 level 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity

2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrated decreased vital capacity

A client with atrial fibrillation is receiving a continuous heparin infusion at 1000 units/hr. The nurse would determine that the client is receiving the therapeutic effect based on which of the following results? 1. Prothrombin time of 12.5 seconds 2. Activated partial thromboplastin time of 60 seconds 3. Activated partial thromboplastin time of 28 seconds 4. Activated partial thromboplastin time longer than 120 seconds

2. Activated partial thromboplastin time of 60 seconds

A client with a clot in the right atrium is receiving a heparin sodium infusion at 1000 units/hour and warfarin sodium 7.5mg at 5:00pm daily. The morning laboratory results are as follows: aPTT: 32 seconds INR: 1.3 The nurse should take which action based on the client's laboratory results? 1. Collaborate with the HCP to discontinue the heparin infusion and administer the warfarin sodium as prescribed 2. Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed 3. Collaborate with the HCP to withhold the warfarin sodium since the client is receiving a heparin infusion and the aPTT is within the therapeutic range 4. Collaborate with the HCP to continue the heparin infusion at the same rate and to discuss use of dabigatran etexilate in place of warfarin sodium

2. Collaborate with the HCP to obtain a prescription to increase the heparin infusion and administer the warfarin sodium as prescribed

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. Comatose state 3. Deep, rapid breathing 5. Elevated blood glucose level 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 byproducts of fat metabolism, build up and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client will become 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 of the body. The body attempts to correct the acidotic state by blowing off 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.

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? 1. Administer a sedative 2. Convey empathy, trust, and respect toward the client 3. Ignore the s/s of anxiety, anticipating that they will soon disappear 4. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening

2. Convey empathy, trust, and respect toward the client Anxiety is a subjective feeling of apprehension, uneasiness, or dread. The appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention and does not address the source of the client's anxiety. The nurse should not ignore the client's anxious feelings. Anxiety needs to be managed before meaningful client education can occur

A nurse is monitoring a client who is taking digoxin for adverse effects. Which findings are characteristic of digoxin toxicity? (select all that apply) 1. Tremors 2. Diarrhea 3. Irritability 4. Blurred vision 5. N/V

2. Diarrhea 4. Blurred vision 5. N/V

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. Inadequate fluid volume 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, 4 are not related specifically to the information in the question

When caring for a client with an internal radiation implant, the nurse should observe which principles? (select all that apply) 1. Limiting the time with the client to 1 hour per shift 2. Keeping pregnant women out of the client's room 3. Placing the client in a private room with a private bath 4. Wearing a lead shield when providing direct client care 5. Removing the dosimeter film badge when entering the client's room 6. Allowing individuals younger than 16 years old in the room as long as they are 6 feet away from the client

2. Keeping pregnant women out of the client's room 3. Placing the client in a private room with a private bath 4. Wearing a lead shield when providing direct client care The time that the nurse spends in the room of a client with an internal radiation implant is 30 minutes per 8-hour shift. The client must be placed in a private room with a private bath. The dosimeter film badge must be worn when in the client's room. Children younger than 16 years of age and pregnant women are not allowed in the client's room.

The nurse is caring for a client with a nasogastric tube that is attached to low suction. The nurse monitors the client for manifestations of which disorder that the client is at risk for? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

2. Metabolic alkalosis

The nurse is preparing to give a bed bath to an immobilized client with TB. The nurse should wear which items when performing this care? 1. Surgical mask and gloves 2. Particulate respiratory, gown, and gloves 3. Particulate respirator and protective eyewear 4. Surgical mask, gown, and protective eyewear

2. Particulate respiratory, gown, and gloves The nurse who is in contact with a client with TB should wear an individually fitted particulate respirator. The nurse also would wear gloves as per standard precautions. The nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bed bath

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? 1. Palpation and clubbing 2. Percussion and vibration 3. Hyperoxygenation and suctioning 4. Administer a bronchodilator and monitor peak flow

2. Percussion and vibration Chest physiotherapy of percussion and vibration helps to loosen secretion sin the smaller lower airways. Postural drainage positions the client so that gravity can help mucus move from smaller airways to larger ones to support expectoration of the mucus. Options 1, 3, 4 are not actions that will loosen secretions

A client has been taking isoniazid for 2 months. The client complains to the nurse about numbness, parasthesias and tingling in the extremities. The nurse interprets that the client is experiencing which problem? 1. Hypercalcemia 2. Peripheral neuritis 3. Small blood vessel spasm 4. Impaired peripheral circulation

2. Peripheral neuritis Isoniazid is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and parathesias in the extremities. This can be minimized with pyridozine (vitamin B12) intake. Options 1, 3, 4 are not associated with the information in the question

The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PaCO2 of 30 mmHg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? 1. Sodium level of 145 mEq/L 2. Potassium level of 3.0 mEq/L 3. Magnesium level of 1.3 mEq/L 4. Phosphorus level of 3.0 mg/dL

2. Potassium level of 3.0 mEq/L

IV heparin therapy is prescribed for a client. While implementing this prescription, the nurse ensures that which medication is available on the nursing unit? 1. Vitamin K 2. Protamine sulfate 3. Potassium chloride 4. Aminocaproic acid

2. Protamine sulfate

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which food? (select all that apply) 1. Peas 2. Raisins 3. Potatoes 4. Cantaloupe 5. Cauliflower 6. Strawberries

2. Raisins 3. Potatoes 4. Cantaloupe 6. Strawberries

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 deserts 5. Carbonated beverages

2. Red meats 3. Whole-grain cereals 5. Carbonated beverages 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 deserts should also be avoided. Even thought the calorie content may be low, carbohydrate content is most likely high and can affect the blood glucose. The items in options 2, 3, 5 are acceptable to consume

The home care nurse visits a client recently diagnosed with diabetes mellitus who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action? 1. Freeze the insulin 2. Refrigerate the insulin 3. Store the insulin in a dark, dry place 4. Keep the insulin at room temperature

2. Refrigerate the insulin Insulin in unopened vials should be stored under refrigeration until needed. Vials should not be frozen. When stored unopened under refrigeration, insulin can be used up to the expiration date on the vial. Options 1, 3, 4 are incorrect.

A client is to begin a 6-month course of therapy with isoniazid. The nurse should plan to teach the client to take which action? 1. Use alcohol in small amounts only 2. Report yellow eyes or skin immediately 3. Increase intake of Swiss or aged cheeses 4. Avoid vitamin supplements during therapy

2. Report yellow eyes or skin immediately Isoniazid is hepatotoxic, and therefore the client is taught to report signs and symptoms of hepatitis immediately, which include yellow skin and sclera. For the same reason, alcohol should be avoided during therapy. The client should avoid intake of swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized y redness and itching of the skin, flushing, sweating, tachycardia, headache, or lightheadedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B12) during the course of isoniazid therapy

The nurse is caring for a client with diabetic ketoacidosis and documents that the client is experiencing Kussmaul's respirations. Which patterns did the nurse observe? (select all that apply) 1. Respirations that are shallow 2. Respirations that are increased in rate 3. Respirations that are abnormally slow 4. Respirations that are abnormally deep 5. Respirations that cease for several seconds

2. Respirations that are increased in rate 4. Respirations that are abnormally deep

The nurse reviews the arterial blood gas results of a client and notes the following: pH: 7.45 PaCO2: 30 mmHg HCO3-: 20 mEq/L The nurse analyzes these results as indicating which condition? 1. Metabolic acidosis, compensated 2. Respiratory alkalosis, compensated 3. Metabolic alkalosis, uncompensated 4. Respiratory acidosis, uncompensated

2. Respiratory alkalosis, compensated

The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure? 1. Beclomethasone first and then salmeterol 2. Salmeterol first and then the beclomethasone 3. Alternating a single puff of each, beginning with the salmeterol 4. Alternating a single puff of each, beginning with the beclomethasone

2. Salmeterol first and then the beclomethasone Salmeterol is an adrenergic type of bronchodilator and beclomethasone dipropionate is a gluccocorticoid. Bronchodilators are always administered before gluccocorticoids when both are to be give on the same time schedule. This allows for widening of the air passages by the bronchodilator which then makes the gluccocorticoid more effective

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 symptom(s) develops? (select all that apply) 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

2. Shakiness 3. Palpitations 5. Lightheadedness Shakiness, palpitations, and lightheadedness are s/s 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 is monitoring a client who is taking propranolol. Which assessment finding indicates a potential adverse complication associated with this medication? 1. The development of complaints of insomnia 2. The development of audible expiratory wheezes 3. A baseline BP of 150/80 mmHg followed by a BP of 138/73 mmHg after 2 doses of the medication 4. A baseline resting heart rate of 88 bpm followed by a resting heart rate of 72 bpm after 2 doses of the medication

2. The development of audible expiratory wheezes

A client with acute myelocytic leukemia is being treated with busulfan. Which laboratory value would the nurse specifically monitor during treatment with this medication? 1. Clotting time 2. Uric acid level 3. Potassium level 4. Blood glucose level

2. Uric acid level Busulfan can cause an increase in the uric acid level. Hyperuricemia can produce uric acid nephropathy, renal stones, and acute kidney injury. Options 1, 3, and 4 are not specifically related to this medication

A client is being treated for heart failure is administered IV bumetanide. Which outcome indicates that the medication has achieved the expected effect? 1. Cough becomes productive of frothy pink sputum 2. Urine output increases from 10mL/hour to greater than 50mL hourly 3. The serum potassium level changes from 3.8 to 3.1 mEq/L 4. B-type natriuretic peptide (BNP) factor increases from 200 to 262 pg/mL

2. Urine output increases from 10mL/hour to greater than 50mL hourly

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease (COPD) to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar

2. Venturi mask The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as COPD, because it delivers a precise oxygen concentration. The face tent, aerosol mask and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity

The nurse should plan to implement which intervention in the care of a client experiencing neutropenia as a result of chemotherapy? 1. Restrict all visitors 2. Restrict fluid intake 3. Teach the client and family about the need for hand hygiene 4. Insert an indwelling urinary catheter to prevent skin breakdown

3. Teach the client and family about the need for hand hygiene In the neutropenic client, meticulous hand hygiene education is implemented for the client, family, visitors, and staff. Not all visitors are restricted, but the client is protected from persons with known infections. Fluids should be encouraged. Invasive measures such as an indwelling urinary catheter should be avoided to prevent infections

The low-pressure alarm sounds on a ventilator. The nurse assess the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? 1. Administer oxygen 2. Check the client's vital signs 3 .Ventilate the client manually 4. Start cardiopulmonary resuscitation

3 .Ventilate the client manually If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin CPR. Check vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the chest

A client newly diagnosed with diabetes mellitus is instructed by the HCP to obtain glucagon for emergency home use. The client asks a home care nurse about the purpose of the medication. What is the nurse's best response to the client's question? 1. "It will boost the cells in your pancreas if you have insufficient insulin" 2. "It will help to promote insulin absorption when your glucose levels are high" 3. "It is for the time when your blood glucose is too low from too much insulin" 4. "It will help to prevent lipoatrophy from the multiple insulin injections over the years"

3. "It is for the time when your blood glucose is too low from too much insulin"

A clinic nurse prepares a teaching plan for a client receiving an antineoplastic medication. When implementing the plan, the nurse should make which statement to the client? 1. "You can take aspirin as needed for headache" 2. "You can drink beverages containing alcohol in moderate amounts each evening" 3. "You need to consult with the health care provider (HCP) before receiving immunizations" 4. "It is fine to receive the flu vaccine at the local health fair without HCP approval because the flu is so contagious"

3. "You need to consult with the health care provider (HCP) before receiving immunizations" Because antineoplastic medications lower the resistance of the body, clients must be informed not to receive immunizations without the HCP's approval. Clients also need to avoid contact with individuals who have recently received a live virus vaccine. Clients need to avoid aspirin and aspirin-containing products to minimize the risk of bleeding, and they need to avoid alcohol to minimize the risk of toxicity and adverse effects

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? 1. Weight loss and dry skin 2. Flat neck and hand veins and decreased urinary output 3. An increase in blood pressure and increased respirations 4. Weakness and decreased central venous pressure (CVP)

3. An increase in blood pressure and increased respirations

The nurse should report which assessment finding to the HCP before initiating thrombolytic therapy in a client with pulmonary embolism? 1. Adventitious breath sounds 2. Temperature of 99.4 F 3. Blood pressure of 198/110 mmHg 4. RR of 28 bpm

3. Blood pressure of 198/110 mmHg

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the HCP? 1. Dry cough 2. Hematuria 3. Bronchospasm 4. Blood-streaked sputum

3. Bronchospasm If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia and dysrhythmias. Hematuria is unrelated to this procedure

A client has been started on long-term therapy with rifampin. The nurse should provide which information to the client about the medication? 1. Should always be taken with food or antacids 2. Should be double-dosed if 1 dose is forgotten 3. Causes orange discoloration of sweat, tears, urine and feces 4. May be discontinued independently if symptoms are gone in 3 months

3. Causes orange discoloration of sweat, tears, urine and feces

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

3. Chest pain that occurs suddenly The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased RR. Other typical symptoms of PE include apprehension and restlessness, tachycardia, cough and cyanosis

Terbutaline is prescribed for a client with bronchitis. The nurse checks the client's medical history for which disorder in which the medication should be used with caution? 1. Osteoarthritis 2. Hypothyroidism 3. Diabetes mellitus 4. Polycystic disease

3. Diabetes mellitus Terbutaline is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimmetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, HTN, hyperparathyroidism, or a history of seizures. The medication may increased blood glucose levels

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? 1. Muscle twitches 2. Decreased urinary output 3. Hyperactive bowel sounds 4. Increased specific gravity of the urine

3. Hyperactive bowel sounds

The nurse is planning to administer hydrochlorothiazide to a client. The nurse should monitor for which adverse effects related to the administration of this medication? 1. Hypouricemia, hyperkalemia 2. Increased risk of osteoporosis 3. Hypokalemia, hyperglycemia, sulfa allergy 4. Hyperkalemia, hypoglycemia, penicillin allergy

3. Hypokalemia, hyperglycemia, sulfa allergy

The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate? 1. Continue to suction 2. Notify the HCP immediately 3. Stop the procedure and reoxygenate the client 4. Ensure that the suction is limited to 15 seconds

3. Stop the procedure and reoxygenate the client During suctioning, the nurse should monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated

A client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose level is 950 mg/dL. A continuous 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. 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. IV fluids containing dextrose Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing 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 250-300mg/dL, the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. 50% 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 is analyzing the lab results of a client with leukemia who has received a regimen of chemotherapy. Which laboratory value would the nurse specifically note as a result of the massive cell destruction that occurred from the chemotherapy? 1. Anemia 2. Decreased platelets 3. Increased uric acid level 4. Decreased leukocyte count

3. Increased uric acid level Hyperuricemia is especially common following treatment for leukemias and lymphomas because chemotherapy results in massive cell kill. Although options 1, 2, 4 also may be noted, an increased uric acid level is related specifically to cell destruction

The nurse is reading a HCP's progress notes in the client's record and reads that the HCP has documented "insensible fluid loss of approximately 800mL daily." The nurse makes a notation that insensible fluid loss occurs through which type of excretion? 1. Urinary output 2. Wound drainage 3. Integumentary output 4. The GI tract

3. Integumentary output

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 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. Intravenous infusion of normal saline The primary goal of treatment in HHS is to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. IV fluid replacement is similar to that administered in DKA and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS

A client with TB is being started on antituberculosis therapy with isoniazid. Before giving the client the first dose, the nurse should ensure that which baseline study has been completed? 1. Electrolyte levels 2. Coagulation times 3. Liver enzyme levels 4. Serum creatinine level

3. Liver enzyme levels Isoniazid therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy. They may be monitored longer in the client who is older than 50 years or abuses alcohol. The laboratory tests in options 1, 2, 4 are not necessary.

A client is diagnosed with an ST segment elevation myocardial infarction (STEMI) and is receiving a tissue plasminogen activator, alteplase. Which action is a priority nursing intervention? 1. Monitor for kidney failure 2. Monitor psychosocial status 3. Monitor for signs of bleeding 4. Have heparin sodium available

3. Monitor for signs of bleeding

The nurse is monitoring a client for signs and symptoms related to superior vena cava syndrome. Which is an early sign of this oncological emergency? 1. Cyanosis 2. Arm edema 3. Periorbital edema 4. Mental status changes

3. Periorbital edema Superior vena cava syndrome occurs when the superior vena cava is compressed or obstructed by tumor growth. Early signs and symptoms generally occur in the morning and include edema of the face, especially around the eyes, and client c/o tightness of a shirt or blouse collar. As the compression worsens, the client experiences edema of the hands and arms. Cyanosis and mental status changes are late signs.

The nurse reviews the arterial blood gas results of an assigned client and notes that the lab report indicates: pH: 7.30 PaCO2: 58 mmHg PaO2: 80 mmHg HCO3: 27 mEq/L The nurse interprets that the client has which acid-base disturbance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3. Respiratory acidosis

The nurse is preparing to administer a dose of naloxone IV to a client with an opioid overdose. Which supportive medical equipment should the nurse plan to have at the client's bedside if needed? 1. Nasogastric tube 2. Paracentesis tray 3. Resuscitation equipment 4. Central line insertion tray

3. Resuscitation equipment The nurse administering naloxone for suspected opioid overdose should have resuscitation equipment readily available to support naloxone therapy if it is needed. Other adjuncts that may be needed include oxygen, a mechanical ventilator, and vasopressors.

The nurse performs an admission assessment on a client with a diagnosis of TB. The nurse should check the results of which diagnostic test that will confirm this diagnosis? 1. Chest x-ray 2. Bronchoscopy 3. Sputum culture 4. Tuberculin skin test

3. Sputum culture TB is definitively diagnosed through culture and isolation of mycobacterum tuberculosis. A presumptive diagnosis is made based on a TB skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy

A client receiving thrombolytic therapy with a continuous infusion of alteplase suddenly becomes extremely anxious and complains of itching. The nurse hears stridor and notes generalized urticaria and hypotension. Which nursing action is the priority? 1. Administer oxygen and protamine sulfate 2. Cut the infusion rate in half and sit the client up in bed 3. Stop the infusion and call for the rapid response team 4. Administer diphenhydramine and epinephrine and continue the infusion

3. Stop the infusion and call for the rapid response team

The nurse review the electrolyte results of an assigned client and notes that the potassium level if 5.7 mEq/L. Which patterns would the nurse watch for on the cardiac monitor as a result of the laboratory value? (select all that apply) 1. ST depression 2. Prominent U wave 3. Tall peaked T waves 4. Prolonged ST segment 5. Widened QRS complex

3. Tall peaked T waves 5. Widened QRS complex

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, temperature of 101 F, pulse of 102 bpm, RR of 22 breaths/min, and blood pressure of 142/72 mmHg. Which finding would be the priority concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure

3. Temperature In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of HHS in the client with type 2 DM. The other findings are within normal limits

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? 1. "I will stop taking my insulin if i'm too sick to eat" 2. "I will decrease my insulin dose during times of illness" 3. "I will adjust my insulin dose according to the level of glucose in my urine" 4. "I will notify my HCP if my blood glucose level is higher than 250 mg/dL)

4. "I will notify my HCP if my blood glucose level is higher than 250 mg/dL) During illness, the client with type 1 diabetes mellitus is at increased risk of DKA, due to hyperglycemia associated with the stress response and due to a typically decreased caloric intake. As part of sick day management, the client with diabetes should monitor blood glucose levels and should notify the HCP if the level is higher than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the HCP's advice and are usually adjusted on the basis of blood glucose levels, not urinary glucose readings

The nurse provides discharge instructions to a client who is taking warfarin sodium. Which statement, by the client, reflects the need for further teaching? 1. "I will avoid alcohol consumption" 2. "I will take my pills every day at the same time" 3. "I have already called my family to pick up a MedicAlert bracelet" 4. "I will take coated aspirin for my headaches because it will coat my stomach"

4. "I will take coated aspirin for my headaches because it will coat my stomach"

The home health care nurse is visiting a client with elevated triglyceride levels and a serum cholesterol level of 398 mg/dL. The client is taking cholestyramine and the nurse teaches the client about the medication. Which statement, by the client, indicates the need for further teaching? 1. "Constipation and bloating might be a problem" 2. "I'll continue to watch my diet and reduce my fats" 3. "Walking a mile each day will help the whole process" 4. "I'll continue my nicotinic acid from the heatlh food store"

4. "I'll continue my nicotinic acid from the heatlh food store"

A client is prescribed nicotinic acid for hyperlipidemia and the nurse provides instructions to the client about the medication. Which statement by the client indicates an understanding of the instructions? 1. "It is not necessary to avoid the use of alcohol" 2. "The medication should be taken with meals to decrease flushing" 3. "Clay-colored stools are a common side effect and should not be of concern" 4. "Ibuprofen IB taken 30 minutes before the nicotinic acid should decrease the flushing"

4. "Ibuprofen IB taken 30 minutes before the nicotinic acid should decrease the flushing"

A client who is receiving digoxin daily has a serum potassium level of 3 mEq/L and is complaining of anorexia. The HCP prescribes a serum digoxin level to be done. The nurse checks the results and should expect to note which level that is outside of the therapeutic range? 1. 0.3 ng/mL 2. 0.5 ng/mL 3. 0.8 ng/mL 4. 1.0 ng/mL

4. 1.0 ng/mL

The nurse is caring for a client admitted to the emergency department with DKA. In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis 2. Administer 5% dextrose IV 3. Apply a monitor for an ECG 4. Administer short-duration insulin IV

4. Administer short-duration insulin IV Lack of insulin (absolute or relative) is the primary cause of DKA. Treatment consists of insulin administration (short or rapid acting), IV 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 ECG monitor is not the priority action

A client with a 3-day history of nausea and vomiting presents to the emergency department. The client is hypoventilating and has a respiratory rate of 10 breaths/minute. The ECG monitor displays tachycardia, with a heart rate of 120 bpm. Arterial blood gases are drawn and the nurse reviews the results, expecting to note which finding? 1. A decreased pH and an increased PaCO2 2. An increased pH and a decreased PaCO2 3. A decreased pH and a decreased HCO3- 4. An increased pH and an increased HCO3-

4. An increased pH and an increased HCO3-

A client is being treated with procainamide for a cardiac dysrhythmia. Following intravenous administration of the medication, the client complains of dizziness. What intervention should the nurse take first? 1. Measure the heart rate on the rhythm strip 2. Administer prescribed nitroglycerin tablets 3. Obtain a 12-lead ECG immediately 4. Auscultate the client's apical pulse and obtain a BP

4. Auscultate the client's apical pulse and obtain a BP

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication? 1. Insomnia 2. Constipation 3. Hypotension 4. Bronchospasm

4. Bronchospasm Cromolyn sodium is an inhaled nonsteroidal antiallergy agent and a mast cell stabilizer. Undesirable effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea and myalgia

The nurse has given a client taking ethambutol information about the medication. The nurse determines that the client understands the instructions if the client states that he or she will immediately report which finding? 1. Impaired sense of hearing 2. GI side effects 3. Orange-red discoloration of body secretions 4. Difficulty in discriminating the color red from green

4. Difficulty in discriminating the color red from green Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptoms immediately. The client is also taught to take the medication with food if GI upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with Rifampin.

The nurse manager is teaching the nursing staff about signs and symptoms related to hypercalcemia in a client with metastatic prostate cancer, and tells the staff that which is a late sign or symptom of this oncological emergency? 1. Headache 2. Dysphagia 3. Constipation 4. ECG changes

4. ECG changes Hypercalcemia is a manifestation of bone metastasis in late-stage cancer. Headache and dysphagia are not associated with hypercalcemia. Constipation may occur early in the process. ECG changes include shortened ST segment and widened T-wave

A client is admitted to the hospital with a suspected diagnosis of Hodgkin's disease. Which assessment finding would the nurse expect to note specifically in the client? 1. Fatigue 2. Weakness 3. Weight gain 4. Enlarged lymph nodes

4. Enlarged lymph nodes Hodgkin's disease is a chronic progressive neoplastic disorder of lymphoid tissue characterized by the painless enlargement of lymph nodes with progression to extra-lymphatic sites, such as the spleen and liver. Weight loss is most likely to be noted. Fatigue and weakness may occur but are not related significantly to the disease

The nurse has conducted discharge teaching with a client diagnosed with TB who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement? 1. "I need to continue medication therapy for 1 month" 2. "I can't shop at the mall for the next 6 months" 3. "I can return to work if a sputum culture comes back negative" 4. "I should not be contagious after 2-3 weeks of medication therapy"

4. I should not be contagious after 2-3 weeks of medication therapy" The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2-3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4. Increased respiratory rate The earliest detectable sign of ARDS is an increased RR, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles

A client who has been taking isoniazid for the past 4 months to treat TB complains to the nurse of experiencing a lack of appetite, nausea and urine output that is dark in color. What should the nurse do?

A major adverse effect of isoniazid is nonviral hepatitis. Signs include anorexia, nausea, vomiting, weakness, fatigue, dark urine, jaundice. If these symptoms occur, the nurse should withhold the medication and notify the health care provider. The nurse should also check the client's liver function test results for elevations, such as ALT (norm: 4-36) AST (norm: 0-35) and the total bilirubin level (norm: 0.3-1.0). If these are elevated, the client could be experiencing nonviral hepatitis.

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? 1. It is timed to release programmed doses of either short-duration or NPH insulin into the blood stream at specific intervals 2. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels 3. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. 4. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal

4. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal An insulin pump provides a small continuous dose of short-duration (rapid or short-acting) insulin subcutaneously throughout the day and night. The client can self-administer an additional bolus dose from the pump before each meal as needed. Short-duration insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas

Prior to administering a client's daily dose of digoxin, the nurse reviews the client's laboratory data and notes the following results: Serum calcium: 9.8 mg/dL Serum magnesium: 1.0 mEq/L Serum potassium: 4.1 mEq/L Serum creatinine: 0.9 mg/dL Which result should alert the nurse that the client is at risk for digoxin toxicity? 1. Calcium 2. Potassium 3. Creatinine 4. Magnesium

4. Magnesium

A client with small cell lung cancer is being treated with etoposide. The nurse monitors the client during administration, knowing that which adverse effect is specifically associated with this medication? 1. Alopecia 2. Chest pain 3. Pulmonary fibrosis 4. Orthostatic hypotension

4. Orthostatic hypotension An adverse effect specific to etoposide is orthostatic hypotension. Etoposide should be administered slowly over 30-60 minutes to avoid hypotension. The client's BP is monitored during the infusion. Hair loss occurs with nearly all antineoplastic medications. Chest pain and pulmonary fibrosis are unrelated to this medication

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? 1. Slow, deep respirations 2. Rapid, deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration

4. Pain, especially with inspiration Rib fractures result from a blunt injury or a fall. Typical s/s include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest

The nurse is caring for a client with hypocalcemia. Which patterns would the nurse watch for on the ECG as a result of the lab value? (select all that apply) 1. U waves 2. Widened T waves 3. Prominent U wave 4. Prolonged QT interval 5. Prolonged ST segment

4. Prolonged QT interval 5. Prolonged ST segment

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? 1. Promote oxygen intake 2. Strengthen the diaphragm 3. Strengthen the intercostal muscles 4. Promote carbon dioxide elimination

4. Promote carbon dioxide elimination Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, 3 are not the purpose of this type of breathing

A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH: 7.12 PaCO2: 90 mmHg HCO3-: 22 mEq/L The nurse interprets the results as indicating which condition? 1. Metabolic acidosis with compensation 2. Respiratory acidosis with compensation 3. Metabolic acidosis without compensation 4. Respiratory acidosis without compensation

4. Respiratory acidosis without compensation

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting up in a recliner chair 4. Sitting up and leaning on an overbed table

4. Sitting up and leaning on an overbed table Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall

The nurse is caring for a client having respiratory distress related to an anxiety attack. Recent arterial blood gas values are: pH: 7.53 PaO2: 72 mmHg PaCO2: 32 mmHg HCO3-: 23 mEq/L Which conclusion about the client should the nurse make? 1. The client has acidotic blood 2. The client is probably overreacting 3. The client is fluid volume overloaded 4. The client is probably hyperventilating

4. The client is probably hyperventilating

Which client is at risk for the development of a potassium level of 5.5 mEq/L? 1. The client with colitis 2. The client with Cushing's syndrome 3. The client who has been overusing laxatives 4. The client who has sustained a traumatic burn

4. The client who has sustained a traumatic burn

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? 1. The client taking diuretics and has tenting of the skin 2. The client with an ileostomy from a recent abdominal surgery 3. The client who requires intermittent gastrointestinal suctioning 4. The client with kidney disease and a 12-year history of diabetes mellitus

4. The client with kidney disease and a 12-year history of diabetes mellitus

A hospitalized client with a diagnosis of abdominal aortic aneurysm suddenly complains of severe back pain and shortness of breath. What should the nurse do?

If the client with an AAA suddenly complains of severe back pain and shortness of breath, the nurse should suspect rupture (a surgical emergency) and should immediately contact the HCP. The nurse should also obtain information about the back pain, stay with the client while waiting for the arrival of the HCP, monitor vital signs and neurological status, and provide support to the client. Other signs of rupture include severe abdominal pain or fullness, soreness over the umbilicus, and sudden development of discoloration in the extremities

A nurse is assessing a client who has respiratory acidosis. Which of the following findings should the nurse expect? a. Confusion b. Peripheral edema c. Facial flushing d. Hyperreflexia

a. Confusion A client who has respiratory acidosis will experience confusion from a lack of cerebral perfusion. If acidosis is not reversed, the client's level of consciousness will decrease and coma may occur.

A nurse is providing dietary teaching to a client who has kidney disease. Which of the following food choices should the nurse include in the teaching as containing the lowest amount of magnesium? a. 1 large hard-boiled egg b. 1 cup bran cereal c. 1/2 cup almonds d. 1 cup cooked spinach

a. 1 large hard-boiled egg One large hard-boiled egg contains 5 mg of magnesium. Therefore, the nurse should recommend this food as containing the lowest amount of magnesium.

A nurse receives prescriptions from a provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription? a. A client who has epistaxis b. A client who has amyotrophic lateral sclerosis c. A client who has pneumonia d. A client who has emphysema

a. A client who has epistaxis The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding. The nurse should identify that a client who has amyotrophic lateral sclerosis can receive nasopharyngeal suctioning. The nurse should identify that a client who has pneumonia can receive nasopharyngeal suctioning The nurse should identify that a client who has emphysema can receive nasopharyngeal suctioning.

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism? a. A client who is 48 hr postoperative following a total hip arthroplasty b. A client who is 8 hr postoperative following an open surgical appendectomy c. A client who is 2 hr postoperative following an open reduction external fixation of the right radius d. A client who is 4 hr postoperative following a laparoscopic cholecystectomy

a. A client who is 48 hr postoperative following a total hip arthroplasty The nurse should identify that the client who has undergone a total hip replacement surgery is at greatest risk for a pulmonary embolus due to decreased mobility of the affected extremity and an increased amount of blood clots form in the veins of the thigh following hip surgery. DVTs are most likely to occur 48-72 hours following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devises or antiembolic stockings and by administering anticoagulant medications.

A nurse is planning care for a client who has experienced excessive fluid loss. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) a. Administer IV fluids to the client evenly over 24 hr b. Provide the client with a salt substitute c. Assess the client for pitting edema d. Encourage the client to rise slowly when standing up e. Weigh the client every 8 hr

a. Administer IV fluids to the client evenly over 24 hr d. Encourage the client to rise slowly when standing up e. Weigh the client every 8 hr

A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement? a. Airborne b. Neutropenic c. Contact d. Droplet

a. Airborne The nurse should initiate airborne precautions for the client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure filtered through a high-efficiency particulate air (HEPA) filter. Members of the healthcare team should not enter the client's room without wearing an N95 respirator mask.

A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? a. Apply supplemental oxygen. b. Increase the rate of IV fluids. c. Administer pain medication. d. Initiate cardiac monitoring.

a. Apply supplemental oxygen. When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen. The nurse should increase the rate of the IV fluid to increase cardiac output. However, another action is the nurse's priority. The nurse should administer pain medication to decrease discomfort and anxiety. However, another action is the nurse's priority. The nurse should initiate cardiac monitoring because the client is at risk for dysrhythmias and right ventricular failure. However, another action is the nurse's priority.

A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect? a. Blood-tinged sputum b. Decreased tactile fremitus c. Resonance with percussion d. Peripheral edema

a. Blood-tinged sputum The nurse should expect blood-tinged sputum secondary to bleeding from the tumor. The nurse should expect an increase in tactile fremitus due to tumor tissue or fluid replacing airspaces. The nurse should expect a dullness or flat sound upon percussion due to the presence of masses in the lungs. The nurse should expect cyanosis of the lips and finger tips, but peripheral edema is not an expected finding for a client who has lung cancer.

A nurse is assessing a client who has hyperkalemia. Which of the following findings should the nurse expect? a. Decreased muscle strength b. Decreased gastric motility c. Increased heart rate d. Increased blood pressure

a. Decreased muscle strength The nurse should expect the client to experience muscle weakness, fatigue, paresthesia, and nausea. The nurse should expect the client to experience increased gastric motility, including abdominal cramps and diarrhea. The nurse should expect the client to experience bradycardia. The nurse should expect the client to experience hypotension.

A nurse is monitoring the lab values of a client who has diabetes mellitus and is taking insulin. Which of the following results indicates a therapeutic outcome of insulin therapy? a. Fasting blood glucose 96 mg/dL b. Postprandial blood glucose 195 mg/dL c. Casual blood glucose 210 mg/dL d. Preprandial blood glucose 60 mg/dL

a. Fasting blood glucose 96 mg/dL This is within the expected reference range for a fasting blood glucose level and indicates that insulin therapy is effective

A nurse is assessing a client who has hypomagnesemia. Which of the following findings should the nurse expect? a. Hyperactive deep-tendon reflexes b. Increased bowel sounds c. Drowsiness d. Decreased blood pressure

a. Hyperactive deep-tendon reflexes Hyperactive deep-tendon reflexes is an expected finding for a client who has hypomagnesemia. Other expected findings include muscle cramps, numbness, and tingling.

While reviewing a client's lab results, a nurse notes a serum calcium level of 8.0 mg/dL. Which of the following actions should the nurse take? a. Implement seizure precautions b. Administer Phosphate c. Initiate diuretic therapy d. Prepare the client for hemodialysis

a. Implement seizure precautions The client is at risk for seizures due to low excitation threshold as a result of a decreased calcium level. The nurse should initiate seizure precautions to prevent injury

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments? a. Presence of gag reflex b. Pain level rating using a 0-10 scale c. Hydration status d. Appearance of the IV insertion site

a. Presence of gag reflex The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex. The client is at risk for increased pain because of the introduction of the scope into the trachea. However, another assessment is the priority. The client who is postoperative following a bronchoscopy has been NPO for 4 to 8 hr, which increases the client's risk for dehydration. The nurse should assess the client's hydration status. However, another assessment is the priority. IV medication given for moderate sedation places the client at risk for phlebitis. Although the nurse should assess for redness, warmth, and drainage at the IV insertion site, another assessment is the priority.

A nurse is admitting a client who has status asthmaticus. The client's ABG results are: pH: 7.32 paO2: 74 mmHg PaCO2: 56 mmHg HCO3: 26 mEq/L The nurse should interpret these lab values as which of the following imbalances? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

a. Respiratory acidosis Status asthmaticus causes inadequate gas exchange, resulting in a low pH and PaO2, an elevated PaCO2, and an HCO3- within the expected reference range. These laboratory values indicate respiratory acidosis.

A nurse is assessing a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse report to the provider? a. Sodium 110 mEq/L b. 2+ deep-tendon reflexes c. Potassium 3.7 mEq/L d. Urine specific gravity 1.025

a. Sodium 110 mEq/L A client who has SIADH retains fluids, which causes dilutional hyponatremia.

A nurse is assessing a client who is receiving hydrochlorothiazide and notes that the client is confused and lethargic. Which of the following lab values should the nurse report to the provider? a. Sodium 128 mEq/L b. Potassium 4.8 mEq/L c. Calcium 9.1 mg/dL d. Magnesium 2.0 mEq/L

a. Sodium 128 mEq/L This level is below the expected reference range and is the likely cause of the client's altered mental status. The nurse should report this finding to the provider and monitor the client for weakened respiratory effort.

A nurse is assisting the provider who is performing a thoracentesis at the bedside of the client. Which of the following actions should the nurse take? (select all that apply) a. Wear goggles and mask during the procedure. b. Cleanse the procedure area with an antiseptic solution. c. Instruct the client to take deep breaths during the procedure. d. Position the client laterally on the affected side before the procedure. e. Apply pressure to the site after the procedure.

a. Wear goggles and mask during the procedure is correct. The nurse and provider should wear goggles and a mask to reduce the risk of exposure to pleural fluid. b. Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk of infection, which is increased due to the invasive nature of the procedure. c. Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk of bleeding at the procedure site. Instruct the client to take deep breaths during the procedure is incorrect. The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk of puncturing the pleura or lung. Position the client laterally on the affected side before the procedure is incorrect. The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid.

A nurse is reviewing the lab values for a client who has diabetic ketoacidosis (DKA). Which of the following results should the nurse expect? a. pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L b. pH 7.38, PaCO2 55 mm Hg, HCO3- 22 mEq/L c. pH 7.44, PaCO2 40 mm Hg, HCO3- 24 mEq/L d. pH 7.50, PaCO2 42 mm Hg, HCO3- 30 mEq/L

a. pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L Metabolic acidosis is a common manifestation of DKA, with pH characteristically low, carbon dioxide within the expected reference range, and bicarbonate low.

A nurse is caring for a client who requires nasogastric suctioning. Which of the following sets of lab results indicates that the client has metabolic alkalosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 26 mEq/L c. pH 7.31, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 23 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

a. pH 7.51, PaO2 94 mm Hg, PaCO2 36 mm Hg, HCO3- 31 mEq/L An elevated pH and HCO3- with a PaCO2 either elevated or within the expected reference range indicates metabolic alkalosis.

A nurse is providing discharge teaching to a client who has diabetes insipidus and a new prescription for desmopressin nasal spray. Which of the following instructions should the nurse include in the teaching? a. "Depress the pump once before using the nasal spray for the first time." b. "Blow your nose gently prior to using the nasal spray." c. "Administer the nasal spray while in a side-lying position." d. "Instill the medication four times per day."

b. "Blow your nose gently prior to using the nasal spray." The nurse should instruct the client to blow his nose gently prior to use of the spray. This action prevents dilution of the medication with nasal secretions.

A nurse is teaching a client about glycosylated hemoglobin (HgbA1C) testing. Which of the following statements should the nurse identify as an indication that the client understands the information about this test? a. "I need to fast after midnight the night before the test." b. "This test's result is a good indicator of my average blood glucose levels." c. "A level of eight to ten percent suggests adequate blood glucose control." d. "I will use my hemoglobin A1c level to adjust my daily insulin doses."

b. "This test's result is a good indicator of my average blood glucose levels." HbA1c reflects the client's glucose levels over a 120-day period, which is the life span of RBCs.

A nurse is caring for a client who is experiencing respiratory distress as a result of pulmonary edema. Which of the following actions should the nurse take first? a. Assist with intubation. b. Initiate high-flow oxygen therapy. c. Administer a rapid-acting diuretic. d. Provide cardiac monitoring.

b. Initiate high-flow oxygen therapy. When using the airway, breathing, circulation approach to client care, the nurse should first administer high-flow oxygen therapy by face mask at 5 to 6 L/min to keep the client's oxygen saturation above 90%. The nurse should administer a rapid-acting diuretic IV bolus to the client to relieve pulmonary congestion; however, there is another action the nurse should take first.

A nurse is admitting a client who takes 40mg furosemide daily for heart failure and has experienced 3 days of vomiting. The nurse suspects hypokalemia. Which of the following medications should the nurse prepare to administer? a. Sodium polystyrene sulfonate 30 g/day b. 0.9% sodium chloride with 10 mEq/L of potassium c. chloride at 100 mL/hr d. Bumetanide 8 mg/day e. 100 mL of dextrose 10% in water with 10 units of insulin

b. 0.9% sodium chloride with 10 mEq/L of potassium This IV solution will provide adequate fluid and potassium replacement to offset the losses from vomiting. The typical amount of potassium chloride to administer IV is 5 to 10 mEq/hr and not to exceed 20 mEq/hr. The dilution should be 1 mEq to 10 mL of 0.9% sodium chloride. Sodium polystyrene sulfonate is an electrolyte cation exchange medication that is given to treat hyperkalemia, not hypokalemia. High-ceiling loop diuretics such as bumetanide are given to treat hyperkalemia, not hypokalemia. Dextrose 10% in water with 10 units of insulin is an IV solution given to treat hyperkalemia, not hypokalemia.

A nurse is providing dietary teaching to a client who has heart failure and is receiving furosemide. Which of the following foods should the nurse recommend as containing the greatest amount of potassium? a. 1/2 cup chopped celery b. 1 cup plain yogurt c. 1 slice whole grain bread d. 1/2 cup cooked tofu

b. 1 cup plain yogurt One cup of plain yogurt contains 380 g of potassium. Therefore, the nurse should recommend this food as containing the greatest amount of potassium.

A nurse is assessing a client who has a serum calcium level of 8.1 mg/dL. Which of the following findings is the priority for the nurse to assess? a. Deep-tendon reflexes b. Cardiac rhythm c. Peripheral sensation d. Bowel sounds

b. Cardiac rhythm When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's cardiac rhythm because this total serum calcium level is below the expected reference range. Hypocalcemia can cause ECG changes, bradycardia, or tachycardia.

A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider? a. Fluctuation of drainage in the tubing with inspiration b. Continuous bubbling in the water seal chamber c. Drainage of 75 mL in the first hour after surgery d. Several small, dark-red blood clots in the tubing

b. Continuous bubbling in the water seal chamber Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while she is waiting for instructions from the provider. Small, dark-red clots are an expected finding for a client after chest surgery. The nurse should continue to monitor the client, but intervention by the nurse is not required at this time.

A nurse is assessing a client who has diabetes mellitus and reports feeling anxious. Which of the following findings should the nurse expect if the client is hypoglycemic? a. Rapid, deep respirations b. Cool, clammy skin c. Abdominal cramping d. Orthostatic hypotension

b. Cool, clammy skin Hypoglycemia causes cool, clammy skin, in addition to anxiety, nervousness, tachycardia, and confusion.

A nurse is assessing a client who is 4 hours postoperative following a total laryngectomy. Which of the following findings is the priority for the nurse to report to the provider? a. Bleeding at the surgical site b. Decreased oxygen saturation c. Urinary retention d. Increased pain level

b. Decreased oxygen saturation Using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia due to airway obstruction.

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? a. Rhonchi on inspiration b. Elevated temperature c. Barrel-shaped chest d. Diminished breath sounds

b. Elevated temperature The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections Diminished breath sounds is an expected finding for clients who have emphysema due to limited chest excursion and air trapping. Rhonchi on inspiration is an expected finding for clients who have emphysema.

A nurse is reviewing the lab report of a client who has fluid volume excess. Which of the following lab values should the nurse expect? a. Hemoglobin 20 g/dL b. Hematocrit 34% c. BUN 25 mg/dL d. Urine specific gravity 1.050

b. Hematocrit 34% The nurse should identify that a client who has fluid volume excess can have a hematocrit level that is below the expected reference range of 37 to 47% for females or 42 to 52% for males. Fluid volume excess can cause hemodilution and a decreased hematocrit level.

A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? a. Lateral position with a pillow at the back and over the chest to support the arm b. High-Fowler's position with the arms supported on the over-bed table c. Semi-Fowler's position with pillows supporting both arms d. Supine position with the head of the bed elevated to 15°

b. High-Fowler's position with the arms supported on the over-bed table The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the over-bed table.

A nurse is assessing a client who has diabetes insipidus. The nurse should expect which of the following findings? a. Decreased heart rate b. Increased hematocrit c. High urine specific gravity d. Low BUN

b. Increased hematocrit An increased hematocrit is an expected finding resulting from dehydration.

A nurse is planning teaching for a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include? a. Consume no more than three servings of alcohol per day. b. Ingest alcohol with food to reduce alcohol-induced hypoglycemia. c. Increase insulin dosage before planned exercise. d. Rest for 3 days between periods of vigorous exercise.

b. Ingest alcohol with food to reduce alcohol-induced hypoglycemia. Alcohol inhibits the liver from producing glucose. Consuming carbohydrates while drinking alcoholic beverages helps prevent hypoglycemia.

A nurse is caring for a client who has diabetes mellitus and has developed peripheral neuropathy. Which of the following measure should the nurse recommend to prevent injuries to the client's feet? a. Examine the skin and feet weekly for alterations in skin integrity. b. Monitor the temperature of bath water with a thermometer. c. Shop for shoes early in the day. d. Round the edges of toenails when trimming them.

b. Monitor the temperature of bath water with a thermometer. Peripheral neuropathy makes it difficult to determine if bath water is too hot. Therefore, to prevent injury, the client should use a bath thermometer to ensure a water temperature below 43.3° C (110° F).

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen? a. Nasal cannula b. Nonrebreather mask c. Simple face mask d. Partial rebreather mask

b. Nonrebreather mask The nurse should use a non-rebreather mask for a client in respiratory distress to provide the highest oxygen level. A non-rebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.

A nurse is planning care for a client who has a serum potassium level of 3.0 mEq/L. The nurse should plan to monitor the client for which of the following findings? a. Hyperactive deep-tendon reflexes b. Orthostatic hypotension c. Rapid, deep respirations d. Strong, bounding pulse

b. Orthostatic hypotension The nurse should plan to monitor the client for orthostatic hypotension, which places him at risk for falls. Orthostatic hypotension is a manifestation of hypokalemia.

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiratory rate is 36/min and he appears very restless. Which of the following values should the nurse anticipate to be outside of the expected reference range if the client is experiencing respiratory alkalosis? a. PaO2 b. PaCO2 c. Sodium d. Bicarbonate

b. PaCO2 The nurse should anticipate that a client who has respiratory alkalosis will have a decreased PaCO2 level due to hyperventilation. The nurse should anticipate that a client who has respiratory alkalosis will have a PaO2 level within the expected reference range. The nurse should anticipate that a client who has respiratory alkalosis will have a sodium level within the expected reference range. The nurse should anticipate that a client who has respiratory alkalosis will have a bicarbonate level within the expected reference range. The bicarbonate level is increased in metabolic alkalosis.

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? a. Increased anterior-posterior chest diameter b. Productive cough with green sputum c. Clubbing of the fingers d. Pursed-lip breathing with exertion

b. Productive cough with green sputum When using the urgent vs non-urgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection. A barrel chest (increased anterior-posterior chest diameter) is non-urgent because it is an expected finding for a client who has COPD. Therefore, there is another finding that is the nurse's priority. Clubbing of the fingers is non-urgent because it is an expected finding for a client who has COPD with chronic low arterial oxygen levels. Therefore, there is another finding that is the nurse's priority. Pursed-lip breathing is non-urgent because it is an expected finding for a client who has COPD. Clients who have COPD use pursed-lip breathing to improve oxygenation when performing physical activity. Therefore, there is another finding that is the nurse's priority.

A nurse is evaluating a client who is receiving IV fluids to treat isotonic dehydration. Which of the following lab findings indicates that the fluid therapy has been effective? a. BUN 26 mg/dL b. Serum sodium 138 mEq/L c. Hct 56% d. Urine specific gravity 1.035

b. Serum sodium 138 mEq/L Isotonic dehydration includes loss of water and electrolytes due to a decrease in oral intake of water and salt. A serum sodium level of 138 mEq/L is within the expected reference range and indicates that the fluid therapy has been effective. A BUN of 26 mg/dL is above the expected reference range. An elevated BUN is an indication that the client is still dehydrated. This Hct is above the expected reference range. An elevated Hct is an indication of that the client is still dehydrated. A urine specific gravity of 1.035 is above the expected reference range. An elevated urine specific gravity is an indication that the client is still dehydrated.

A nurse is caring for a client who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take? a. Use clean technique when suctioning the client's endotracheal tube. b. Use a rotating motion when removing the suction catheter. c. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube. d. Suction the client's endotracheal tube every 2 hr.

b. Use a rotating motion when removing the suction catheter. The nurse should rotate the suction catheter during withdrawal to reduce the risk of tissue trauma.

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include? a. "Ringing in the ears is an adverse effect of this medication." b. "Have your skin test repeated in 4 months to show a positive result." c. "Expect your urine and other secretions to be orange while taking this medication." d. "Remember to take this medication with a sip of water just before your first bite of each meal."

c. "Expect your urine and other secretions to be orange while taking this medication." The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur including jaundice, fatigue or malaise.

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the clients indicates an understanding of the teaching? a. "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma." b. "I should cut a 4-inch gauze dressing and place it around my tracheostomy tube to absorb drainage." c. "I should remove the old twill ties after the new ties are in place." d. "I should apply suction while inserting the catheter into my tracheostomy tube."

c. "I should remove the old twill ties after the new ties are in place." As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. This practice can prevent accidental decannulation.

A nurse is teaching a client who has type 1 diabetes mellitus about how to prevent complications during illness. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "I should stop taking my insulin if I feel nauseous." b. "I will test my urine for protein when I start to feel ill." c. "I will call my doctor if my blood sugar is more than 250 milligrams per deciliter." d. "I should check my blood glucose level every 8 hours."

c. "I will call my doctor if my blood sugar is more than 250 milligrams per deciliter." The client should call the provider if her blood glucose levels exceed 250 mg/dL during illness.

A nurse is providing teaching for a client who has venous insufficiency of the lower extremities. Which of the following statements by the client indicates an understanding of the teaching? a. "If my stockings feel tight, I'll just roll them down for a while." b. "I'll put on my elastic stockings at the first sign of swelling." c. "When I sit down to watch television, I'll be sure to put my feet up." d. "It's okay to cross my legs as long as it's for less than an hour."

c. "When I sit down to watch television, I'll be sure to put my feet up." Venous insufficiency makes it difficult for blood flow to return to the heart. Elevating her feet will increase the return. The client should elevate her feet for at least 20 min several times per day.

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? a. BP b. Capillary Refill c. ABGs d. HR

c. ABGs When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

A nurse is caring for a client who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? a. Excess secretions b. Kinks in the tubing c. Artificial airway cuff leak d. Biting on the endotracheal tube

c. Artificial airway cuff leak An artificial airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound. An excess of secretions in the airway causes the high pressure alarm to sound. Kinks in the tubing can cause an obstruction, which causes the high pressure alarm to sound. Biting on the endotracheal tube causes the high pressure alarm to sound.

A nurse is preparing to administer oral potassium for a client who has a potassium level of 5.5 mEq/L. Which of the following actions should the nurse take first? a. Administer a hypertonic solution. b. Repeat the potassium level. c. Withhold the medication. d. Monitor for paresthesia

c. Withhold the medication. The greatest risk to the client is bradycardia, hypotension, and life-threatening cardiac complications due to hyperkalemia, defined as a potassium level above 5.0 mEq/L. Therefore, the nurse's priority action is to withhold the oral potassium and notify the provider

A nurse is caring for a client who is receiving furosemide daily. During the morning assessment, the client tells the nurse that he is "feeling weak in the legs". Which of the following actions should the nurse take first? a. Monitor the client's bowel sounds. b. Review the client's daily laboratory results. c. Auscultate the client's lungs. d. Palpate the client's peripheral pulses.

c. Auscultate the client's lungs. An adverse effect of many diuretics, including furosemide, is hypokalemia. When using the airway, breathing, circulation approach to client care, the nurse should first auscultate the client's lungs to assess for respiratory changes due to weakness of the respiratory muscles. An adverse effect of many diuretics, including furosemide, is hypokalemia. The nurse should palpate the client's peripheral pulses to assess for cardiovascular changes, such as a thready and weak pulse. However, there is another action the nurse should take first. An adverse effect of many diuretics, including furosemide, is hypokalemia. The nurse should review the client's daily laboratory results, especially his potassium level. However, there is another action the nurse should take first.

A nurse is caring for a client who has dehydration and is receiving IV fluids. When assessing for complications, the nurse should recognize which of the following manifestations as a sign of fluid overload? a. Increased urine specific gravity b. Hypoactive bowel sounds c. Bounding peripheral pulses d. Decreased respiratory rate

c. Bounding peripheral pulses The nurse should recognize that increased vascular volume results in full, bounding peripheral pulses.

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? a. Extra drainage system b. Suture removal set c. Container of sterile water d. Nonadherent pads

c. Container of sterile water The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected in order to prevent a pneumothorax.

A nurse is teaching a client who has diabetes mellitus about insulin injections. The client's prescription includes evening doses of insulin glargine and regular insulin. Which of the following instructions should the nurse include? a. Inject the insulins intramuscularly. b. Shake the insulins vigorously prior to administration. c. Draw up the insulins into separate syringes. d. Expect the insulins to appear cloudy.

c. Draw up the insulins into separate syringes The nurse should instruct the client to draw up the insulins into separate syringes because insulin glargine is not compatible with other insulins.

A nurse is caring for a client who is 1 hour postoperative following a thoracentesis. Which of the following is the priority assessment finding? a. Pallor b. Insertion site pain c. Persistent cough d. Temperature 37.3° C (99.1° F)

c. Persistent cough When using the airway, breathing, circulation approach to client care, the nurse determines that the priority finding is persistent cough because this indicates a tension pneumothorax, which is a medical emergency.

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? a. Schedule respiratory treatments following meals. b. Have the client sit up in a chair for 2-hr periods three times per day. c. Provide a diet that is high in calories and protein. d. Combine activities to allow for longer rest periods between activities.

c. Provide a diet that is high in calories and protein. The nurse should provide the client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

A nurse is assessing a client who is using PCA following a thoracotomy. The client is short of breath, appears restless, and has a respiratory rate of 28/min. The client's ABG results are: pH 7.52 PaO2: 89 mmHg PaCO2: 28 mmHg HCO3: 24 mEq/L Which of the following actions should the nurse take? a. Instruct the client to cough forcefully. b. Assist the client with ambulation. c. Provide calming interventions. d. Discontinue the PCA.

c. Provide calming interventions. The client's respiratory rate is above the expected range. Calming the client should decrease the respiratory rate, which will cause the client's carbon dioxide levels to increase to expected levels of 35 to 45 mm Hg and lower the pH to expected levels of 7.35 to 7.45. The nurse should instruct the client to breathe slowly.

A nurse is reviewing the medical record of a client who has diabetes mellitus and is receiving regular insulin by continuous IV infusion to treat diabetic ketoacidosis. Which of the following findings should the nurse expect to report to the provider? a. Urine output of 30 mL/hr b. Blood glucose of 180 mg/dL c. Serum potassium 3.0 mEq/L d. BUN 18 mg/dL

c. Serum potassium 3.0 mEq/L This serum potassium level is below the expected reference range. Hypokalemia is a serious complication that can occur when a client who has diabetic ketoacidosis is receiving insulin to treat the condition. The nurse should report this finding to the provider.

A nurse is assessing a client with a phosphorus level of 2.4 mg/dL. Which of the following should the nurse expect? a. Hepatic failure b. Abdominal pain c. Slow peripheral pulses d. Increase in cardiac output

c. Slow peripheral pulses This phosphorus level is below the expected reference range. The nurse should expect the client to have slow peripheral pulses. The nurse might also find that the client's pulses are difficult to find and easy to block.

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? a. Hyperkalemia b. Dyspnea c. Tachycardia d. Candidiasis

c. Tachycardia The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis. The nurse should monitor the client for hypokalemia, which is a potential adverse effect of albuterol. The nurse should monitor the client for a decrease in dyspnea. A decrease in dyspnea is a therapeutic effect of albuterol, not an adverse effect. The nurse should monitor the client who is taking an inhaled glucocorticoid, such as beclomethasone for candidiasis.

A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect? a. Decreased fremitus b. SaO2 95% on room air c. Temperature 38.8° C (101.8° F) d. Bradypnea

c. Temperature 38.8° C (101.8° F) An elevated temperature is an expected finding for a client who has bacterial pneumonia. Increased fremitus is an expected finding for a client who has bacterial pneumonia. An oxygen saturation level lower than 95% is an expected finding for a client who has bacterial pneumonia. Tachypnea is an expected finding for a client who has bacterial pneumonia.

A nurse is teaching nutritional strategies to a client who has low serum calcium level and an allergy to milk. Which of the following statements by the client indicates an understanding of the teaching? a. "I will eat more cheese because I can't drink milk." b. "I need to avoid foods with vitamin D because I am allergic to milk." c. "I will stop taking my calcium supplements if they irritate my stomach." d. "I will add broccoli and kale to my diet."

d. "I will add broccoli and kale to my diet." The nurse should recommend that the client consume broccoli and kale, which are good sources of calcium, as alternatives to dairy products.

A nurse in an outpatient clinic is teaching a client who has a diabetic foot ulcer about foot care. Which of the following statements should the nurse identify as an indication that the client understands the teaching? a. "I will let my feet air dry after washing." b. "I will wear sandals to allow air to circulate around my feet." c. "I will buy over-the-counter medicine to treat the calluses on my feet." d. "I will apply lotion to the dry areas of my feet, but not between my toes."

d. "I will apply lotion to the dry areas of my feet, but not between my toes." Lotion can be used for dry areas of the feet, but the client should avoid applying lotion between the toes, as this area is prone to bacterial growth.

A nurse is providing teaching to a client who has chronic asthma and a new prescription for montelukast. Which of the following client statements indicates an understanding of the teaching? a. "I will monitor my heart rate every day while taking this medication." b. "I will make sure I have this medication with me at all times." c. "I will need to carefully rinse my mouth after I take this medication." d. "I will take this medication every night even if I don't have symptoms."

d. "I will take this medication every night even if I don't have symptoms."

A nurse is providing teaching for a client who is at risk for developing respiratory acidosis following surgery. Which of the following statements by the client indicates an understanding of the teaching? a. "I should conserve energy by limiting my physical activity." b. "I will wait until my pain is at least six out of ten before I use the PCA." c. "I will limit my daily fluid intake to two to three glasses." d. "I will use the incentive spirometer every hour."

d. "I will use the incentive spirometer every hour." Respiratory depression and limited chest expansion are both causes of respiratory acidosis. Therefore, using an incentive spirometer will promote adequate chest expansion.

A nurse is caring for a client who has a sodium level of 155 mEq/L. Which of the following IV fluids should the nurse anticipate the provider to prescribe? a. Dextrose 5% in 0.9% sodium chloride b. Dextrose 5% in lactated Ringer's c. 3% sodium chloride d. 0.45% sodium chloride

d. 0.45% sodium chloride A sodium level of 155 mEq/L is an indication of hypernatremia. The nurse should anticipate a prescription for a hypotonic solution. The 0.45% sodium chloride is a hypotonic solution used to provide free water and treat cellular dehydration, which promotes waste elimination by the kidneys.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority? a. Provide a quiet environment b. Encourage use of incentive spirometry every 1 to 2 hr c. Obtain a blood sample for electrolyte study d. Administer heparin via continuous IV infusion

d. Administer heparin via continuous IV infusion Using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention. The nurse should obtain a blood sample from a client who has a pulmonary embolism to send to the lab for coagulation studies, electrolyte levels, and a CBC. However, another intervention is the nurse's priority. The nurse should encourage the client who has a pulmonary embolism to use an incentive spirometer to improve oxygenation and ventilation. However, another intervention is the nurse's priority.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? a. Cromolyn sodium b. Prednisone c. Fluticasone/salmeterol d. Albuterol

d. Albuterol The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack. The nurse should administer cromolyn sodium, an anti-inflammatory agent, for maintenance therapy of asthma, not for treatment during an acute asthma attack. The nurse should administer prednisone following an acute attack to promote anti-inflammatory effects. The nurse should administer fluticasone/salmeterol for maintenance therapy of asthma because it combines a glucocorticoid and a long-acting beta2-adrenergic agonist.

A nurse is providing teaching to a client who has Hodgkin's Lymphoma and is undergoing external radiation treatment. Which of the following instructions should the nurse include? a. Use an antibacterial soap to cleanse the skin. b. Wash the ink marking off when showering. c. Rub the skin with a towel when drying. d. Avoid direct sun exposure to the skin.

d. Avoid direct sun exposure to the skin. The nurse should instruct the client to avoid sun exposure because the client's skin is sensitive to sunburn due to the external radiation. The nurse should instruct the client to cleanse his skin with mild soap and water because the client's skin is fragile due to the external radiation. The client should avoid antibacterial soaps because they can irritate the skin. The nurse should instruct the client not to remove the ink or dye markings because they identify the location of the site that is being radiated. The nurse should instruct the client to pat, rather than rub, the skin dry to avoid damage to the skin.

A nurse is teaching a client who has diabetes mellitus. Which of the following should the nurse include as an expected finding of diabetic ketoacidosis (DKA)? a. Decreased urine output b. Weight gain of 0.45 kg (1 lb) in 24 hr c. Rapid, shallow respirations d. Blood glucose levels above 300 mg/dL

d. Blood glucose levels above 300 mg/dL Blood glucose levels above 300 mg/dL are an expected finding with DKA. Levels above 600 mg/dL are an expected finding with hyperglycemic-hyperosmolar state.

A nurse is caring for a client who has non-Hodgkin's lymphoma and is receiving chemotherapy. Which of the following is the priority assessment finding? a. Loss of body hair b. Report of anorexia c. Mucositis of the oral cavity d. Erythema at the IV insertion site

d. Erythema at the IV insertion site The greatest risk to the client is injury to the tissue due to extravasation of chemotherapy. Erythema at the IV insertion site can indicate extravasation is occurring, which can lead to infection and tissue loss. This is the priority assessment finding.

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? a. Decreased bowel sounds b. Oxygen saturation 92% c. CO2 24 mEq/L d. Intercostal retractions

d. Intercostal retractions The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS. The nurse should identify that decreased bowel sounds is an expected finding for a client who has ARDS. The nurse should identify that an oxygen saturation 92% is within the expected reference range for a client who has ARDS. The nurse should identify that a CO2 of 24 mEq/L is within the expected reference range for a client who has ARDS.

A nurse is assessing a client who has dehydration. Which of the following assessments is priority? a. Skin turgor b. Urine output c. Weight d. Mental status

d. Mental status The greatest risk to this client is injury from a fall due to a decline in the client's mental status. Therefore, assessing the client's mental status is the nurse's priority. The nurse should assess urine output to monitor the client's hydration status. Decrease urine output is a manifestation of dehydration. However, another assessment is the nurse's priority.

A nurse in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? a. Arterial pH 7.50 b. PaCO2 25 mm Hg c. SaO2 92% d. PaO2 58 mm Hg

d. PaO2 58 mm Hg The nurse should expect the client who has acute respiratory failure to have lower partial pressures of oxygen. The nurse should expect a decreased pH level because respiratory failure can cause respiratory acidosis. The nurse should expect the carbon dioxide level to rise with acute respiratory failure. The nurse should expect the client who has acute respiratory failure to have a decrease in oxygen saturation.

A nurse is caring for a client who requires continuous cardiac monitoring. The nurse identifies a prolonged PR interval and a widened QRS complex. Which of the following lab values supports this finding? a. Sodium 152 mEq/L b. Chloride 102 mEq/L c. Magnesium 1.8 mEq/L d. Potassium 6.1 mEq/L

d. Potassium 6.1 mEq/L Hyperkalemia, defined as a potassium level above 5.0 mEq/L, can cause a prolonged PR interval, a wide QRS complex, flat or absent P waves, and tall, peaked T waves.

A nurse is preparing a teaching plan for a client who has diabetes insipidus and requires intranasal desmopressin. Which of the following information should the nurse include in the teaching plan? a. Drink at least 3 L of fluid per day. b. Weigh yourself weekly while wearing similar clothing at the same time of day. c. Notify the provider of a weight loss of 0.45 kg (1 lb) or more per week. d. Report nocturia because it requires a dosage adjustment.

d. Report nocturia because it requires a dosage adjustment. The client should receive the initial dose of desmopressin in the evening; the provider will increase the dosage until the client no longer has nocturia.

A nurse is caring for a client who has type 2 diabetes mellitus and has hyperglycemic-hyperosmolar state (HHS). Which of the following lab findings should the nurse expect? a. Serum pH of 7.32 b. Blood glucose of 250 mg/dL c. Blood glucose of 425 mg/dL d. Serum pH of 7.45

d. Serum pH of 7.45 A client who has HHS produces enough insulin to prevent ketosis, but not enough to prevent hyperglycemia. Therefore, the serum pH is within the expected reference range. Glucose levels will be above 600 mg/dL.

A nurse working in the emergency department is caring for a client following an acute chest trauma. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax? a. Collapsed neck veins on the affected side b. Collapsed neck veins on the unaffected side c. Tracheal deviation to the affected side d. Tracheal deviation to the unaffected side

d. Tracheal deviation to the unaffected side The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is reviewing ABG results for four clients. Which of the following findings should the nurse identify as metabolic acidosis? a. pH 7.51, PaO2 94 mm Hg, PaCO2 38 mm Hg, HCO3- 29 mEq/L b. pH 7.48, PaO2 89 mm Hg, PaCO2 30 mm Hg, HCO3- 24 mEq/L c. pH 7.36, PaO2 77 mm Hg, PaCO2 52 mm Hg, HCO3- 26 mEq/L d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L

d. pH 7.26, PaO2 84 mm Hg, PaCO2 38 mm Hg, HCO3- 20 mEq/L A pH below 7.35 is an indication of acidosis. HCO3- below 22 mEq/L is an indication of metabolic acidosis.

A nurse is caring for a client who is postoperative and has a RR of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis? a. pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L b. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L c. pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L d. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L

d. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.