EXAM 2 -ATI questions - random

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority? 1) Give the client 15 to 20 g of carbohydrate. 2) Monitor the client for hypoglycemia. 3) Complete an incident report. 4) Notify the nurse manager.

2) Monitor the client for hypoglycemia.

A charge nurse is teaching a group of nurses about conditions related to metabolic acidosis. Which of the following statements by unit nurse indicates the teaching has been effective? A. "metabolic acidosis can occur due to diabetic ketoacidosis." B. " metabolic acidosis can occur in a client who has myasthenia gravis." C. "metabolic acidosis can occur in a client who has asthma." D. "metabolic acidosis can occur due to cancer."

A. "metabolic acidosis can occur due to diabetic ketoacidosis." Metabolic acidosis results from an excess production of hydrogen ions, which occurs in diabetic ketoacidosis.

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client's clotting factors are depleted? (Select all that apply.) A. Platelets 100,000/mm3B. Fibrinogen levels 57 mg/dL C. Fibrin degradation products 4.3 mcg/mL D. D‑dimer 0.03 mcg/mL E. Sedimentation rate 38 mm/hr

A. Platelets 100,000/mm3 B. Fibrinogen levels 57 mg/dL In DIC, platelet levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage.In DIC, fibrinogen levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage.

A nurse is assessing a client who has a head injury following a motor-vehicle crash. The nurse should identify that which of the following findings indicates increasing intracranial pressure? A. Restlessness B. Dizziness C. Hypotension D. Fever

A. Restlessness

A nurse is caring for a client who has type 2 diabetes mellitus and is admitted with hyperglycemic-hyperosmolar state (HHS). Which of the following laboratory findings should the nurse expect? a. Blood glucose of 496 mg/dL and serum pH of 7.32 b. Blood glucose of 550 mg/dL and serum pH of 7.02 c. Blood glucose of 702 mg/dL and serum pH of 6.11 d. Blood glucose of 846 mg/dL and serum pH of 7.40

Blood glucose of 846 mg/dL and serum pH of 7.40

A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small‑vessel clotting when which of the following is assessed? A. Petechiae on the upper chest B. Hypotension C. Cyanotic nail beds D. Severe headache

C. Cyanotic nail beds Cyanotic nail beds indicate microvascular clotting is occurring and should be immediately reported to avoid ischemic loss of the fingers or toes.

A nurse is monitoring a client who had a cerebral aneurysm rupture. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. irritability b. tachycardia c. hypotension d. tinnitus

a irritability

A nurse is reviewing laboratory 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

pH 7.32, PaCO2 36 mm Hg, HCO3- 14 mEq/L With DKA, the pH is low, carbon dioxide is within the expected reference range, and bicarbonate is low.

A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering? A. Heparin B. Vitamin K C. Mefoxin D. Simvastatin

A. Heparin Heparin can be administered to decrease the formation of microclots, which deplete clotting factors.

A nurse is planning care for a client who has septic shock. Which of the following is the priority action for the nurse to take? A. Maintaining adequate fluid volume with IV infusions B. Administering antibiotic therapy C. Monitoring hemodynamic status D. Administering vasopressor medication

B. Administering antibiotic therapy Using the safety and risk reduction framework, administration of antibiotics is the priority action by the nurse. Eliminating endotoxins and mediators from bacteria will reduce the vasodilation that is occuring

A nurse is teaching a newly licensed nurse about heparin‑induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching? A. Warfarin therapy for atrial fibrillation B. Placental abruption C. Systemic lupus erythematosus D. Heparin therapy for deep‑vein thrombosis

D. Heparin therapy for deep‑vein thrombosis The client who is receiving heparin therapy for longer than 1 week is at increased risk for the development of HIT.

A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate? A. Bradycardia B. Hypertension C. Epistaxis D. Xerostomia

C. Epistaxis Epistaxis is unexpected bleeding of the gums and nose and is a finding indicative of DIC.

A nurse is reviewing the medical record for client who is to begin therapy for DKA. Which of the following prescriptions should the nurse expect?A. administer an IV infusion of regular insulin at 0.3 unit/kg/hrB. administer a slow IV infusion of 3% sodium chlorideC. rapidly administer an IV infusion of 0.9% sodium chlorideD. add glucose to the IV infusion when blood glucose is 350 mg/dL

C. rapidly administer an IV infusion of 0.9% sodium chloride

Question: A client who is diagnosed with diabetic ketoacidosis has a serum glucose level of 580 mg/dL and a potassium level of 5.7 mEq/L. Vital signs include: Blood pressure 88/54 mm Hg; Heart rate 136/min; Respiratory rate 40/min. Which action should the nurse implement first? A. Reassess serum blood glucose level. B. Begin potassium replacement therapy. C. Administer 6 units regular insulin subcutaneously. D. Infuse 1 liter of 0.9% sodium chloride over an hour.

CORRECT ANSWER: D Rationale A. The nurse should reassess blood glucose every hour to evaluate the effectiveness of therapy. When the blood glucose level reaches 300 mg/dL, IV solutions containing dextrose should be initiated to prevent hypoglycemia and cerebral edema. B. Serum potassium levels drop once therapy is initiated. Potassium replacement is started after serum potassium levels fall below 5.0 mEq/L. The maximum infusion rate for adults should not exceed 10 mEq of potassium per hour. C. Subcutaneous insulin has a delayed onset of action and should be administered once the client can take oral fluids and ketosis has stopped. Therefore, unless DKA is mild, a continuous IV infusion of regular insulin should be started. An initial IV bolus of regular insulin may be given at the beginning of the infusion. D. CORRECT: The priority action is to restore volume and maintain perfusion to the brain, heart and kidneys. Hyperglycemia leads to osmotic diuresis and dehydration resulting in tachycardia and hypotension. Typically, 1 liter of 0.9% sodium chloride is administered over one hour. Lost volume as well as ongoing fluid losses should be replaced

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

d. pH 7.45 a client who is experiencing HHS produces enugh insulin to prevent ketosis bt not enough to prevent hyperglycemia. Therfore, the pH is within expected reference range. Glucose in HHS is > 600

A nurse is caring for a client who has a basilar skull fracture following a fall from a ladder. Which of the following assessment findings should the nurse report to the provider? A. Glasgow Coma Scale score of 15 B. Intracranial pressure reading of 15 mm Hg C. Ecchymosis at base of skull D. Clear drainage from nose

D. Clear drainage from nose

A nurse is assessing a client who is quadriplegic following a cervical fracture at vertebral level C5. The client reports a throbbing headache and nausea. The nurse notes facial flushing and a blood pressure of 220/110mm Hg. Which of the following actions should the nurse take first? A. Administer hydralazine via IV bolus B. Loosen the client's clothing C. Empty the client's bladder D. Elevate the head of the client's bed

D. Elevate the head of the client's bed

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 of DKA. Levels above 600 mg/dL are an expected finding in a client who is in a hyperglycemic-hyperosmolar state. DKA: increased urine output, weight loss, deep labored breathing (kussmaul) are expected in DKA.

A nurse is planning care for a client who has a closed traumatic brain injury from a fall and is receiving mechanical ventilation. Which of the following intervention is the nurse's priority? A. Maintain a PaCO2 of approx. 35 mmHg B. Provide small doses of fentanyl via bolus for pain management C. Measure body temperature every 1-2hr D. Reposition the client every 2 hr

A. Maintain a PaCO2 of approx. 35 mmHg

A nurse is providing discharge teaching to a client who had diabetic ketoacidosis. Which of the following information should the nurse include about preventing DKA? (Select all that apply.) A. drink 2L fluids daily B. monitor blood glucose every 4 hr when ill C. administer insulin as prescribed when ill D. notify the provider when blood glucose is 200 mg/dL E. report ketones in the urine after 24 hr of illness

A. drink 2L fluids daily, B. monitor blood glucose every 4 hr when ill , C. administer insulin as prescribed when ill, E. report ketones in the urine after 24 hr of illness

A nurse is reviewing the health history of a client who has diabetes mellitus type 2. Which of the following are risk factors for hyperglycemia-hyperosmolar state (HHS)? (Select all that apply.) A. evidence of recent myocardial infarction B. BUN 35 mg/dL C. takes a calcium channel blocker D. age 77 years E. daily insulin injections

A. evidence of recent myocardial infarction, B. BUN 35 mg/dL , C. takes a calcium channel blocker, D. age 77 years

A nurse is reviewing laboratory reports of client who has HHS. Which of the following findings should the nurse expect? A. blood pH 7.2 B. blood osmolarity 350 mOsm/L C. blood potassium 3.8 mg/dL D. blood creatinine 0.8 mg/dL

B. blood osmolarity 350 mOsm/L

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply.) A. weight gain B. fruity odor of breath C. abdominal pain D. Kussmaul respirations E. metabolic acidosis

B. fruity odor of breath C. abdominal pain D. Kussmaul respirations E. metabolic acidosis

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

a. "I will call my doctor if my blood sugar is more than 250." The client should call the provider if their blood glucose levels exceed 250 mg/dL during illness. the client should check their blood glucose level every 4 hr during illness. the client should check their urine for ketones when blood glucose levels are > 240 mg/dL. the client should continue taking the usual dose of insulin even when not feeling well.

A nurse is planning care for a client who has a new diagnosis of diabetes insipidus. Which of the following interventions should the nurse include in the plan of care? a. measure blood glucose levels every 4 hours b. administer a diuretic c. initiate fluid restrictions d. check urine specific gravity

d. check urine specific gravity