Exam 3 (Final) Powerpoint Questions

After teaching a patient who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the patient's understanding. Which statement by the patient indicated a correct understanding of the teaching? a. "I will avoid sources of strong electromagnetic fields" b. "Now I can discontinue my antidysrhythmic medication" c. "I should participate in a strenuous exercise program" d. "I should wear a snug-fitting shirt over the ICD"

a "I will avoid sources of strong electromagnetic fields"

A nurse assesses a patient on the medical-surgical unit. Which statement made by the patient alerts the nurse to assess the patient for hypothyroidism? a. "I am always tired, even with 12 hours of sleep." b. "Food just doesn't taste good without a lot of salt." c. "My sister has thyroid problems." d. "I seem to feel the heat more than other people."

a. "I am always tired, even with 12 hours of sleep."

The home health nurse visits a client with a. diagnosis of type 1 diabetes mellitus. The client reports 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? a. "I need to stop my insulin" b. "I need to increase my fluid intake" c. "I need to monitor my blood glucose every 3 to 4 hours" d. "I need to call my primary health care provider (PHCP) because of these symptoms."

a. "I need to stop my insulin"

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? a. "I should consume less than 1 liter of fluid per day" b. "I should use a treadmill or go for walks daily" c. "I should follow a moderate-calcium, high-fiber diet" d. "My alendronate helps keep calcium from coming to of my bones"

a. "I should consume less than 1 liter of fluid per day"

A nurse teaches a patient who experiences occasional premature atrial contractions (PACs) accompanied by palpations that resolve spontaneously without treatment. Which statement would the nurse include in this patient's teaching? a. "Minimize or abstain from caffeine" b. "Lie on your side until the attack subsides" c. "Use your oxygen when you experience PACs" d. "Take amiodarone (Cordarone) daily to prevent PACs"

a. "Minimize or abstain from caffeine"

A nurse is caring for a patient who was prescribed high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition. The patient's symptoms have now resolved and the patient asks, "When can I stop taking these medications?" How would the nurse respond? a. "Once you start corticosteroids, you have to be weaned off them." b. "You must decrease the dose slowly so your hormones will work again." c. "It is possible for the inflammation to recur if you stop the medication." d. "The drug suppresses your immune system, which must be built back up."

a. "Once you start corticosteroids, you have to be weaned off them."

A patient who smokes asks the nurse, "Smoking just hurts my lungs, not my heart, right?" Which nursing response is appropriate? a. "Smoking is a major risk factor of coronary artery disease and peripheral vascular disease." b. "You are correct, smoking only hurts the lungs." c. "The primary impact of smoking is only on the heart" d. "What concerns you most about smoking?"

a. "Smoking is a major risk factor of coronary artery disease and peripheral vascular disease."

A nurse evaluates the following laboratory results for a patient who has hypoparathyroidism: Calcium 7.2 mg/dL (1.8 mmol/L) Sodium 144 mEq/L (144 mmol/L) Magnesium 1.2 mEq/L (0.6 mmol/L) Potassium 5.7 mEq/L (5.7 mmol/L) Based on these results, which medications does the nurse anticipate administering? (Select all that apply.) a. 50% magnesium sulfate b. Oral calcitriol (Rocaltrol) c. Oral potassium chloride d. Intravenous calcium chloride e. 3% normal saline IV solution

a. 50% magnesium sulfate d. Intravenous calcium chloride

A nurse assesses a patient who has diabetes mellitus and notes that the patient is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup (120 mL) of orange juice, the patient's clinical manifestations have not changed. What action would the nurse take next? a. Administer another half-cup (120 mL) of orange juice b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.

a. Administer another half-cup (120 mL) of orange juice

The nurse suspects that a patient is deficient in thyroid-stimulating hormone. What assessment findings would correlate to this condition? (Select all that apply.) a. Decreased libido b. Weight gain c. Alopecia d. Hyperactivity

a. Decreased libido b. Weight gain c. Alopecia

A nurse evaluates laboratory results for a patient with heart failure. Which results would the nurse expect? (Select all that apply) a. Hematocrit: 32.8% b. Proteinuria c. Serum creatinine: 1.0 mg/dL (88.4 mcmol/L) d. Serum sodium: 130 mEq/L (130 mmol/L) e. Serum potassium: 4.0 mEq/L (4.0 mmol/L)

a. Hematocrit: 32.8% b. Proteinuria d. Serum sodium: 130 mEq/L (130 mmol/L)

A nurse teaches a patient with hyperthyroidism. Which dietary modifications should the nurse include in this patient's teaching? (Select all that apply.) a. Increased calorie intake b. Increased proteins c. Increased carbohydrates d. Decreased fats

a. Increased calorie intake b. Increased proteins c. Increased carbohydrates

An emergency department nurse assesses a patient with ketoacidosis. Which clinical manifestation would the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Severe orthostatic hypotension d. Oral temperature of 102° F (38.9° C)

a. Increased rate and depth of respiration

A nurse assesses a patient with anterior pituitary hyperfunction. Which clinical manifestations would the nurse expect? (Select all that apply.) a. Protrusion of the lower jaw b. High-pitched voice c. Enlarged hands and feet d. Barrel-shaped chest

a. Protrusion of the lower jaw c. Enlarged hands and feet

A nurse cares for a patient who is recovering from a pituitary gland resection (hypophysectomy). What action would the nurse take first? a. Report clear or light yellow drainage from the nose. b. Instruct the patient to cough, turn, and deep breathe. c. Apply petroleum jelly to lips to avoid dryness d. Keep the head of the bed flat and the patient supine

a. Report clear or light yellow drainage from the nose.

A nurse cares for a patient who is prescribed vasopressin (DDAVP) for diabetes insipidus. Which assessment findings indicate a therapeutic response to this therapy? (Select all that apply.) a. Specific gravity is increased. b. Urine output is increased. c. Specific gravity is decreased. d. Urine osmolality is decreased. e. Urine osmolality is increased. f. Urine output is decreased.

a. Specific gravity is increased. e. Urine osmolality is increased. f. Urine output is decreased.

While assessing a patient with Graves' disease, the nurse notes that the patient's temperature has risen 1° F (1° C). What does the nurse do first? a. Turn the lights down and shut the patient's door. b. Administer a dose of acetaminophen (Tylenol). c. Calculate the patient's apical-radial pulse deficit. d. Call for an immediate electrocardiogram (ECG).

a. Turn the lights down and shut the patient's door.

A nurse assesses a patient's electrocardiograph tracing and observes that not all QRS complexed are preceded by a P wave. How would the nurse interpret this observation? a. ventricular and atrial depolarizations are initiated from different sites b. the patient has hyperkalemia causing irregular QRS complexes c. Ventricular tachycardia is overriding the normal atrial rhythm d. the patient's chest leads are not making sufficient contact with the skin

a. Ventricular and atrial depolarizations are initiated from different sites

A nurse in the medical field is caring for a client with heart failure. The client suddenly develops extreme dyspnea, tachycardia, and lung crackles. The nurse immediately asks another nurse to contact the primary health care provider and prepares to implement which priority interventions? Select all that apply a. administer oxygen b. inserting a foley catheter c. administer furosemide d. administer morphine sulfate intravenously e. transporting the client to the coronary care unit f. placing the client in a low-fowler's side-lying position

a. administer oxygen b. inserting a foley catheter c. administer furosemide d. administer morphine sulfate intravenously

A nurse assesses a patient with Cushing's disease. Which assessment findings would the nurse correlate with this disorder? (Select all that apply.) a. Weight loss b. Muscle atrophy c. Hypotension d. Moon face e. Petechiae

b. Muscle atrophy d. Moon face e. Petechiae

A nurse cares for a patient who has a heart rate averaging 46 beats/min with no adverse symptoms. Which activity modification wold the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm" b. "Avoid straining whole having a bowel movement" c. "Limit your intake of caffeinated drinks to one a day" d. "Avoid strenuous exercise such as running"

b. "Avoid straining whole having a bowel movement" *stimulate vagal nerve*

A nurse teaches a patient who is prescribed an unsealed radioactive isotope. Which statements will the nurse include in this patient's education? (Select all that apply.) a. "You can play with your grandchildren for 1 hour each day." b. "Do not share utensils, plates, and cups with anyone else." c. "Wash your clothing separate from others in the household." d. "Take a laxative 2 days after therapy to excrete the radiation."

b. "Do not share utensils, plates, and cups with anyone else." c. "Wash your clothing separate from others in the household." d. "Take a laxative 2 days after therapy to excrete the radiation."

A patient with hypertension is discussing the cause of hypertension. Which statement by the nurse is appropriate? a. "Pregnancy can cause essential hypertension" b. "High cholesterol can be a big factor in development of essential hypertension" c. "Stopping intake of caffeine can cause hypertension to go away" d. "Race is associated with secondary hypertension"

b. "High cholesterol can be a big factor in development of essential hypertension"

A nurse assesses a patient in an outpatient clinic. Which statement alerts the nurse to the possibility of left-sided heart failure? a. "I am awakened by the need to urinate at night." b. "I must stop halfway up the stairs to catch my breath." c. "I have been drinking more water than usual" d. "I have experienced blurred vision on several occasions."

b. "I must stop halfway up the stairs to catch my breath."

After teaching a patient who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the patient's understanding. Which statement by the patient indicates a correct understanding of the teaching? a. "I should wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields" c. "I should participate in a strenuous exercise program" d "Now I can discontinue my antidysrhythmic medication"

b. "I will avoid sources of strong electromagnetic fields"

A client with type 1 diabetes mellitus who takes NPH daily in the morning 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? a. "I should not exercise since I am taking insulin" b. "The best time for me to exercise is after breakfast" c. "The best time for me to exercise is mid- to late afternoon" d. "NPH is a basal insulin, so I should exercise in the evening"

b. "The best time for me to exercise is after breakfast"

The nurse is caring for four clients with a history of hypertension. Which client would require intervention? a. 40 yr old with chronic kidney disease, BP 138/80 b. 58 yr old on diuretics, BP 160/80 c. 28 yr old with LDL-C 140 md/dL, CP 114/84 d. 30 yr old with pre-eclampsia, BP 120/68

b. 58 yr old on diuretics, BP 160/80

A nurse assesses patients for potential endocrine disorders. Which patient is at greatest risk for hyperparathyroidism? a. A 72-year-old male who is prescribed home oxygen therapy b. A 41-year-old male receiving dialysis for end-stage kidney disease c. A 29-year-old female with pregnancy-induced hypertension d. A 66-year-old female with moderate heart failure

b. A 41-year-old male receiving dialysis for end-stage kidney disease

A nurse assesses a patient who is recovering from a total thyroidectomy and notes the development of stridor. What action does the nurse take first? a. Reassure the patient that the voice change is temporary. b. Contact the provider and prepare for intubation. c. Document the finding and assess the patient hourly. d. Place the patient in high-Fowler's position and apply oxygen

b. Contact the provider and prepare for intubation.

The nurse is caring for a patient on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm. After calling for assistance and a defibrillator, what action would the nurse take next? a. start an 18 gauge intravenous line b. initiate cardiopulmonary resuscitation (CPR) c. ask the patient's family about code status d. perform a pericardial thump

b. Initiate cardiopulmonary resuscitation (CPR)

A nurse cares for a patient who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? a. Propranolol (Inderal) b. Levothyroxine sodium (Synthroid) c. Atropine sulfate d. Epinephrine (Adrenalin)

b. Levothyroxine sodium (Synthroid)

The nurse is evaluating a client's response to cardioversion. Which assessment would be the priority? a. blood pressure b. airway patency c. oxygen flow rate d. level of consciousness

b. airway patency

The nurse is caring for a client after hypophysectomy and notes clear nasal drainage from the client's nostril. The nurse should take which initial action? a. lower the head of the bed b. test the drainage for glucose c. obtain a culture of the drainage d. continue to observe the drainage

b. test the drainage for glucose

A patient has recently been admitted with a diagnosis of coronary artery disease. What lab assessments would the nurse anticipate? (select all that apply) a. total cholesterol 120 mg/dL (normal 150-250 mg/dL) b. triglycerides 168 mg/dL (normal 75-165 mg/dL) c. HDL 32 mg/dL (normal 34-69 mg/dL) d. CRP 0.8 mg/dL (normal <3.0 mg/L) e. LDL 600 mg/dL (normal 105-180 mg/dL)

b. triglycerides 168 mg/dL (normal 75-165 mg/dL) c. HDL 32 mg/dL (normal 34-69 mg/dL) e. LDL 600 mg/dL (normal 105-180 mg/dL)

A client with a myocardial infarction is developing cariogenic shock. What condition should the nurse carefully assess the client for? a. pulses paradoxus b. ventricular dysrhythmias c. rising diastolic blood pressure d. falling central venous pressure

b. ventricular dysrhythmias

Which priority question should the nurse ask a patient with a pituitary tumor? a. "Have you had an unexpected weight loss?" b. "Have you notices a change in your libido?" c. "Do you have any changes in your visual acuity?" d. "Have you experienced a change in growth of your facial hair?"

c. "Do you have any changes in your visual acuity?"

A nurse assesses a patient admitted to the cardiac unit. Which statement by the patient alerts the nurse to the possibility of right-sided heart failure? a. "I have trouble catching my breath." b. "I wake up coughing every night." c. "My shoes fit really tight lately" d. "I sleep with four pillows at night"

c. "My shoes fit really tight lately"

A nurse assesses a patient with diabetes mellitus and notes that the patient only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL (1.8 mmol/L), and has an intravenous line that is infiltrated with 0.45% normal saline. What action would the nurse take first? a. Insert a new intravenous access line. b. Encourage the patient to drink orange juice. c. Administer 1 mg of intramuscular glucagon. d. Administer 25 mL dextrose 50% (D50) IV push.

c. Administer 1 mg of intramuscular glucagon.

A nurse assesses a patient after a cardiac angiography via the left femoral artery. The nurse notes that the left pedal pulse is weak. Which action would the nurse take? a. elevate the leg and apply a sandbag to the entrance site b. increase the flow rate of intravenous fluids c. assess the color and temperature of the left leg d. document the finding as "left pedal pulse is +1/4"

c. Assess the color and temperature of the left leg *determine if clot is present *for answer a: lifting the leg will reduce blood flow to extremities artery = takes blood away from heart vein = takes blood towards the heart

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (52.9 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.3 mmol/L). The nurse would next prepare to administer which medication? a. an ampule of 50% dextrose b. NPH insulin subcutaneously c. IV fluids. containing dextrose d. phenytoin for the prevention of seizures

c. IV fluids containing dextrose

A nurse reviews the laboratory results of a patient who is receiving intravenous insulin. Which would alert the nurse to intervene immediately? a. Serum calcium level of 8.8 mg/dL (2.2 mmol/L) b. Serum chloride level of 98 mEq/L (98 mmol/L) c. Serum potassium level of 2.5 mEq/L (2.5 mmol/L) d. Serum sodium level of 132 mEq (132 mmol/L)

c. Serum potassium level of 2.5 mEq/L (2.5 mmol/L)

The nurse is performing an assessment on a client with pheochromocytoma. Which assessment data would indicate a potential complication associated with this disorder? a. a urinary output of 50 mL/hr b. a coagulation time of 5 minutes c. a heart rate that is 90 beats per minute and irregular d. a blood urea nitrogen level of 20mg/dL (7.1 mmol/L)

c. a heart rate that is 90 beats per minute and irregular

The nurse is evaluating the condition of a client after periocaardiocentesis performed to treat cardiac tamponade. Which observation would indicate that the procedure was effective? a. muffled heart sounds b. client reports dyspnea c. a rise in blood pressure d. jugular venous distention

c. a rise in blood pressure

A patient presents to the ED and is diagnosed with an acute MI. The patient's spouse asks what type of damage has been caused by the "heart attack". What is the appropriate nursing response? a "The pain is controlled, so there is no damage" b. "It will take years to know the extent of the damage to the heart muscle" c. "The medication will dilate the blood vessels and any damage will be corrected" d. "A heart attack evolves over several hours. We won't know the extent of the damage immediately"

d. "A heart attack evolves over several hours. We won't know the extent of the damage immediately"

After teaching a patient who is recovering from a complete thyroidectomy, the nurse assesses the patient's understanding. Which statement made by the patient indicates a need for additional instruction? Select one: a. "I may need calcium replacement after surgery." b. "I'll need to take thyroid hormones for the rest of my life." c. "I can receive pain medication if I feel that I need it." d. "After surgery, I won't need to take thyroid medication."

d. "After surgery, I won't need to take thyroid medication."

At 4:45 PM, a nurse assesses a patient with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the patient is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS) Dietary Intake At 06:30—95At 11:30—70At 16:30—47 Breakfast: 10% eaten—patient states that she is not hungryLunch: 5% eaten—patient is nauseous; vomits once After reviewing the patient's assessment data, which action is appropriate at this time? a. Reorient the patient and apply a cool washcloth to the patient's forehead. b. Assess the patient's oxygen saturation level and administer oxygen. c. Provide a glass of orange juice and encourage the patient to eat dinner. d. Administer dextrose 50% intravenously and reassess the patient.

d. Administer dextrose 50% intravenously and reassess the patient.

A nurse is interested in providing community education and screening on hypertension. In order to reach a priority population, to that target audience would the nurse provide this service? a. women's health clinics b. asian-americas groceries c. high-school sports camps d. african-american churches

d. African-american churches

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? a. correct the acidosis b. administer 5% dextrose intravenously c. apply a monitor for an electrocardiogram d. administer short-duration insulin intravenously

d. administer short-duration insulin intravenously

A patient is 4 hours postoperative after a femoral-popliteal bypass. The patient reports throbbing leg pain on the affected side, rate as 7/10. What action by the nurse takes priority? a. administer pain medication as ordered b. document the findings in the patient's chart c. notify the surgeon immediately d. assess distal pulses and skin color

d. assess distal pulses and skin color

While assessing a patient on a cardiac unit, a nurse identifies the presence of an S3 gallop (extra heart sound). What action would the nurse take next? a. document this as a normal finding b. transfer the patient to the intensive care unit c. call the healthcare provider immediately d. assess for symptoms of left-sided heart failure

d. assess for symptoms of left-sided heart failure

What is the most common symptom when patient is diagnosed with hypertension? a. headache b. slurred speech c. fainting and dizziness d. hypertension is often asymptomatic

d. hypertension is often asymptomatic *silent killer*

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? a. hoarseness b. hypocalcemia c. audible stridor d. edema at the surgical site

c. audible stridor

The nurse should evaluate that defibrillation of a client was most successful if which observation was made? a. arousable, sinus rhythm, blood pressure (BP) 116/72 mmHG b. nonarousable, sinus rhythm, BP 88/60 mmHg c. arousable, marked bradycardia, BP 86/54 mmHG d. nonarousable, supra ventricular tachycardia, BP 122/60 mmHG

a. arousable, sinus rhythm, blood pressure (BP) 116/72

A patient has been diagnosed with hypertension but does not take the antihypertensive medications because of a lack of symptoms. What response by the nurse is best? a. "Most people with hypertension do not have symptoms" b. "You are lucky; most people get severe morning headaches" c. "You need to take your medicine or you will get kidney failure" d. "Do you have trouble affording your medications"

a. "Most people with hypertension do not have symptoms"

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? Select all that apply a. fever b. nausea c. lethargy d. tremors e. confusion f. bradycardia

a. fever b. nausea d. tremors e. confusion

A client with a diagnosis of addisonian crisis is being admitted to the intensive care unit. Which findings will the inter professional health care team focus on? Select all that apply a. hypotension b. leukocytosis c. hyperkalemia d. hypercalcemia e. hypernatremia

a. hypotension c. hyperkalemia

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (ADHD) and has serum sodium of 118 mEq/L (118 mmol/L). Which primary health care provider prescriptions should the nurse anticipate receiving? select all that apply a. initiate an infusion of 3% NaCl b. administer intravenous furosemide c. restrict fluids to 800 mL over 24 hours d. elevate the head of bed to high-Fowler's e. administer a vasopressin antagonist as prescribed

a. initiate an infusion of 3% NaCl c. restrict fluids to 800 mL over 24 hours e. administer a vasopressin antagonist as prescribed

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if frequently exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? a. polyuria b. diaphoresis c. pedal edema d. decreased respiratory rate

a. polyuria

The nurse is completing an assessment on a client who is being admitted for a diagnosis workup for primary hyperparathyroidism. Which client complaints would be characteristic of this disorder? Select all that apply a. polyuria b. headache c. bone pain d. nervousness e. weight gain

a. polyuria c. bone pain

The client has developed atrial fibrillation with a ventricular rate of 150 beats per minute. The nurse should assess the client for which associated signs and/or symptoms? Select all that apply a. syncope b. dizziness c. palpitations d. hypertension e. flat neck veins

a. syncope b. dizziness c. palpitations

The nurse is assessing the neurovauscular status of a client who returned to the surgical nursing unit 4 hours ago after undergoing aortoiliac bypass graft. The affected leg I swarm, and the nurse notes redness and edema. The pedal pulse is palpable. How should the nurse interpret the client's neuromuscular status? a. the neuromuscular status is normal because of increased blood flow through the leg b. the neuromuscular status is moderately impaired, and the surgeon should be called c. the neuromuscular status is slightly deteriorating and should be monitored for another hour d. the neuromuscular status shows adequate arterial flow, but venous complications are arising

a. the neuromuscular status his normal because of increased blood flow through the leg

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 a. tremors b. anorexia c. irritability d. nervousness e. hot, dry skin f. muscle cramps

a. tremors c. irritability d. nervousness

Identify the laboratory test that is most specific for myocardial infarction and cardiac necrosis. a. troponin b. HDL c. CK-MB d. CK

a. troponin

The nurse is caring for a client who has just had implantation of an automatic internal cardioverter-defibrillator. The nurse should assess which item based on priority? a. anxiety level of the client and family b. activation status and settings of the device c. presence of a MedicAlert card for the client to carry d. knowledge of restrictions on post discharge physical activity

b. activation status and settings of the device

A client who had cardiac surgery 24 hours ago has had a urine output averaging 20 mL/hr for 2 hours. The client received a single bolus of 500mL of intravenous fluid. Urine output for the subsequent hour was 25 mL. Daily laboratory results indicate that the blood urea nitrogen level is 45 mg/dL (16 mmol/L) and the serum creatinine level is 2.2 mg/dL (194 mcmol/L). On the basis of these findings, the nurse would anticipate that the client is at risk for which problem? a. hypovolemia b. acute kidney injury c. glomerulonephritis d. urinary tract infection

b. acute kidney injury

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 a. increase in PH b. comatose state c. deep, rapid breathing d. decreased urine output e. elevated blood glucose level

b. comatose state c. deep, rapid breathing e. elevated blood glucose level

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? a. administer a sedative b. convey empathy, trust, and respect toward the client c. ignore the signs and symptoms of anxiety, anticipating that they will soon disappear d. make sure that the client is familiar with the correct medical terms to promote understanding of what is happening

b. convey empathy, trust, and empathy toward the client

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? a. lack of knowledge b. inadequate fluid volume c. compromised family coping d. inadequate consumption of nutrients

b. inadequate fluid volume

The nurse is monitoring a client diagnosed with acromegaly who was treated with transsphenoidal hypophysectomy and is recovering in the intensive care unit. Which findings should alert the nurse to the presence of a possible postoperative complications? select all that apply a. anxiety b. leukocytosis c. chvostek's sign d. urinary output of 800 mL/hr e. clear drainage on nasal dripper pad

b. leukocytosis d. urinary output of 800 mL/hr e. clear drainage on nasal dripper pad

A client is admitted to an emergency department and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? a. warm the client b. maintain a patent airway c. administer thyroid hormone d. administer fluid replacement

b. maintain a patent airway

The nurse teaches a client with diabetes about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of this teaching by stating that a form of glucose should be taken if which symptoms develop? select all that apply a. polyuria b. shakiness c. palpitations d. blurred vision e. lightheadedness f. purity breath odor

b. shakiness c. palpitations e. lightheadedness

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? Select all that apply a. tremors b. weight loss c. feeling cold d. loss of body hair e. persistent lethargy f. puffiness of the face

c. feeling cold d. loss of body hair e. persistent lethargy f. puffiness of the face

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated primary health care provider's prescription? a. endotracheal intubation b. 100 units of NPH insulin c. intravenous infusion of normal saline d. intravenous infusion of sodium bicarbonate

c. intravenous infusion of normal saline

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 70 mg/dL, (3.9 mmol/L), temperature of 101 F (38.3 C), pulse of 82 beats per minute, respirations of 20 breaths per minute, and blood pressure o f118/68 mmHg. Which finding would be the priority concern to the nurse? a. pulse b. respirations c. temperature d. blood pressure

c. temperature

The nurse notes that a client with sinus rhythm has a premature ventricular contraction that falls on the T wave of the preceding beat. The client's rhythm suddenly changes to one with no P waves, no definable QRS complexes, and coarse wavy lines of varying amplitude. How should the nurse interpret this rhythm? a. asystole b. atrial fibrillation c. ventricular fibrillation d. ventricular tachycardia

c. ventricular fibrillation

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? a. "I will stop taking my insulin if I'm too sick to eat" b. "I will decrease my insulin dose during times of illness" c. "I will adjust my insulin dose according to the level of glucose in my urine" d. "I will notify my health care provider (PHCP) if my blood glucose level is higher that 250 mg/dL"

d. "I will notify my health care provider (PHCP) if my blood glucose level is higher that 250 mg/dL"

A client with variant angina is scheduled to receive an oral calcium channel blocker twice daily. Which statement by the client indicates the need for further teaching? a. "I should notify my my cardiologist if my feet or legs start to swell" b. "I am supposed to report to my cardiologist if my pulse rate decreases below 60" c. "Avoiding grapefruit juice will definitely be a challenge for me, since I usually drink it every morning with breakfast" d. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning"

d. "My spouse told me that since I have developed this problem, we are going to stop walking in the mall every morning"

The nurse is caring for a client who had a resection of an abdominal aortic aneurysm yesterday. The client has an intravenous (IV) infusion at a rate of 150 mL/hr, uncharged for the last 10 hours. The client's drone output for the last 3 hours has been 90, 50, and 28 mL (28 mL is most recent). The client's blood urea nitrogen level is 35 mg/dL. (12.6 mmol/L), and the serum creatinine level is 1.8 mg/dL (159 mmol/L), measures this morning. Which nursing action is the priority? a. check the serum albumin level b. check the urine specific gravity c. continue monitoring urine output d. call the primary health care provider (PHCP)

d. call the primary health care provider (PHCP)

An external insulin pumps prescribed to 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? a. it is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals b. it continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels c. it is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream d. 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

d. 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

A nurse assesses a patient with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. mild orthostatic hypotension b. increased urine output c. P wave touching the T wave d. midsternal chest pain

d. midsternal chest pain

A nurse is caring for a patient with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (Select all that apply.) a. assess blood urea nitrogen (BUN) and creatine results b. administer intravenous fluids c. administer a prophylactic antibiotic d. assess for allergies to iodine e. insert a Foley catheter

a. assess blood urea nitrogen (BUN) and creatinine results b. administer intravenous fluids d. assess for allergies of iodine

A nurse is caring for a patient with a history of renal insufficiency who is scheduled for a cardiac catheterization. What actions would the nurse take prior to the catheterization? (select all that apply) a. assess for allergies to iodine b. administer intravenous fluids c. assess blood urea nitrogen (BUN) and creatinine results d. insert a foley catheter

a. assess for allergies to iodine b. administer intravenous fluids *good for dye purposes, but not a priority* c. assess blood urea nitrogen (BUN) and creatinine results *elevated levels*

The nurse is watching the cardiac monitor, and a client's rhythm suddenly changes. There are no P waves; instead, there are fibrillatory waves before each QRS complex. How should the nurse interpret the client's heart rate? a. atrial fibrillation b. sinus tachycardia c. ventricular fibrillation d. ventricular tachycardia

a. atrial fibrillation

When developing a postoperative plan of care for a patient after a total thyroidectomy, the nurse knows the plan should indicate which intervention? a. avoiding extending the patient's neck b. assessing the patient's voice once per shift c. encouraging the patient to be out of bed in a chair d. administer oxygen via nasal cannula as needed

a. avoiding extending the patient's neck

A client is admitted to the emergency department with chest pain that is consistent with myocardial infarction based on elevated troponin levels. Heart sounds are normal. The nurse should alert the primary health care provider the vital sign changes and client assessment are most consistent with which complication? refer to chart a. cardiogenic shock b. cardiac tamponade c. pulmonary embolism d. dissecting thoracic aortic aneurysm

a. cardiogenic shock

A nurse cares for a patient with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations would the nurse assess? (select all that apply) a. decrease in cardiac output b. increase in cardiac output c. decrease in blood pressure d. increase in blood pressure e. decrease in urine output f. increase in urine output

a. decrease in cardiac output c. decrease in blood pressure e. decrease in urine output

Which does the nurse identify as an assessment finding that may indicate an age-related decrease in antidiuretic hormone (ADH)? a. diluted urine and dehydration b. yeast infection and polydipsia c. higher than normal body weight d. constipation, lethargy, and dry skin

a. diluted urine and dehydration

As the nurse is assessing a patient with Grave's disease, which finding requires immediate attention? a. elevates temperature b. elevated blood pressure c. change in respiratory rate d. irregular heart rate and rhythm

a. elevated temperature

What is the priority nursing intervention for an older female patient with a history of hyperparathyroidism? a. implement fall precautions b. encourage oral fluid hydration c. encourage small frequent meals d. provide pain medications as prescribed

a. implement fall precautions

A client's electrocardiogram strip shows atrial and ventricular rates of 110 beats per minute. The PR interval is 0.14 seconds, the QRS complex measures 0.08 seconds and the PP and RR intervals are regular. How should the nurse interpret this rhythm? a. sinus tachycardia b. sinus bradycardia c. sinua dysrhtymias d. normal sinus rhythm

a. sinus tachycardia

A client is wearing a continuous cardiac monitor, which begins to sound its alarm. The nurse sees no electrocardiographic complexes on the screen. Which is the priority nursing action? a. call a code b. check the client's status c. call the health care provider d. document the lack of complexes

b. check the client's status

When caring for a patient having a hypoglycemic episode, the nurse knows which symptoms requires immediate intervention? a. hunger b. confusion c. headache d. tachycardia

b. confusion

A nurse is assessing a patient with left-sided heart failure. For which clinical manifestations would the nurse assess? a. pulmonary hypertension b. confusion, restlessness c. dependent edema d. pulmonary crackles e. cough that worsens at night

b. confusion, restlessness d. pulmonary crackles e. cough that worsens at night

A nurse cares for a patient who possibly has syndrome of inappropriate antidiuretic hormone (SIADH). The patient's serum sodium level is 114 mEq/L (114 mmol/L). What action would the nurse take first? a. Consult with the dietitian about increased dietary sodium b. Handle the patient gently by using turn sheets for repositioning. c. Restrict the patient's fluid intake to 600 mL/day. d. Instruct unlicensed assistive personnel to measure intake and output.

c. Restrict the patient's fluid intake to 600 mL/day.

A nurse cares for a patient who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification would the nurse suggest to avoid further slowing the heart rate? a. "Limit your intake of caffeinated drinks to one a day" b. "Make certain that your bath water is warm" c. "Avoid strenuous exercise such as running" d. "Avoid straining while having a bowel movement"

d. "Avoid straining while having a bowel movement"

A nurse cares for a patient recovering from prosthetic valve replacement surgery. The patient asks, "Why will I need to take anticoagulants for the rest of my life?" What is the best response by the nurse? a. "The prosthetic valve places you at greater risk for a heart attack" b. "The surgery left a lot of small clots in your heart and lungs" c. "The vein taken from your leg reduces circulation in the leg" d. "Blood clots form more easily in artificial replacement valves"

d. "Blood clots form more easily in artificial replacement valves"

A patient has peripheral arterial disease (PAD). What statement by the patient indicated misunderstanding about self-management activities? a. "I should not cross my legs when sitting or lying down" b. "It's going to be really hard but I will stop smoking" c. "I will go out and buy some warm, heavy socks to wear d. "I can use a heating pas on my legs if its set on low"

d. "I can use a heating pad on my legs if its set on low"

A client in sinus bradycardia, with a heart rate of 45 beats per minute and blood pressure 82/60 mmHg, reports dizziness. Which intervention should the nurse anticipate will be prescribed? a. administer digoxin b. defibrillate the client c. continue to monitor the client d. prepare for transcutaneous pacing

d. prepare for transcutaneous pacing

A nurse assesses a patient's electrocardiogram (ECG) and observes the reading. How would the nurse document this patient's ECG strip? a. ventricular tachycardia b. sinus rhythm with premature atrial contractions (PACs) c. ventricular fibrillation d. sinus rhythm with premature ventricular contractions (PVCs)

d. sinus rhythm with premature ventricular contractions (PVCs)

A nurse assesses a patient with atrial fibrillation. Which manifestation would alert the nurse to the possibility of a serious complication from this condition? a. sinus tachycardia b. dyspnea with activity c. fatigue d. speech alterations

d. speech alterations

The nurse is caring for a patient diagnosed with small cell lung cancer. The nurse understands the patient may also present with which endocrine disorder? a. adrenal crisis b. cushion's syndrome c. diabetes insipidus (DI) d. syndrome of inappropriate antidiuretic hormone (SIADH)

d. syndrome of inappropriate antidiuretic hormone (SIADH)

A women has been experiencing atypical angina. What symptoms would the nurse anticipate? (select all that apply) a. vomiting b. indigestion c. aching jaw pain d. depression e. irregular bowel movement f. decreased patterns of activity

b. indigestion c. aching jaw pain e. irregular bowel movements

A client has frequent bursts of ventricular tachycardia on the cardiac monitor. What should the nurse be most concerned about with this dysrhythmia? a. It can develop into ventricular fibrillation at any time. b. It is almost impossible to convert to a normal rhythm. c. It is uncomfortable for the client, giving a sense of impending doom. d. It produces a high cardiac output that quickly leads to cerebral and myocardial ischemia.

a. it can develop into ventricular fibrillation at any time

A nurse is teaching a group of patients about metabolic syndrome. Which assessment features are associated with the syndrome? (select all that apply) a. male waist circumference 44 inches b. fasting blood glucose 66 mg/dL c. triglyceride value of 162 mg/dL d. blood pressure 135/85 e. patient is taking blood pressure medication

a. male waist circumference 44 inches c. triglyceride value of 162 mg/dL d. blood pressure 135/85 e. patient is taking blood pressure medication

A client with myocardial infarction suddenly becomes tachycardia, shows signs of air hunger, and begins coughing frothy, pink-tinges sputum. Which finding would the nurse anticipate when auscultating the client's breath sounds? a. stridor b. crackles c. scattered rhonchi d. diminished breath sounds

b. crackles

The nurse expects what outcome in a patient who is taking a beta blocker for mild heart failure? a. improved urinary output b. improved activity tolerance c. increased myocardial contractility d. increased myocardial oxygen

b. improved activity tolerance

A nurse is caring for a patient on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below. After calling for assistance and a defibrillator, what action would the nurse take next? a. perform a pericardial thump b. initiate cardiopulmonary resuscitation (CPR) c. start and 18-gauge intravenous line d. ask the patient's family about code status

b. initiate cardiopulmonary resuscitation (CPR)

A client with a. history of type 2 diabetes is admitted to the hospital with chest pain. The client is scheduled for a cardiac catheterization. Which medication would need to be withheld for 24 hours before the procedure and for 48 hours after the procedure? a. glipizide b. metformin c. repaglinide d. regular insulin

b. metformin

A nurse is caring for a patient with a deep vein thrombosis (DVT). What nursing assessment indicated that a priority outcome has been met? a. verbalizing risk factors b. oxygen saturation of 98% c. ambulates with assistance d. pain of 2/10 after medication

b. oxygen saturation of 98%

A nurse evaluates prescriptions for a patient with chronic atrial fibrillation. Which medication would the nurse expect to find on this patient's medication administration record to prevent a common complication of this condition? (select all that apply) a. atropine b. warfarin (Coumadin) c. lidocaine d. intravenous heparin

b. warfarin (Coumadin) d. intravenous heparin

A nurse assesses a patine who is scheduled for a cardiac catheterization. Which assessment would the nurse complete prior to this procedure? a. ability to turn self in bed b. cardiac rhythm and heart rate c. allergies to iodine-based agents d. patient's level of anxiety

c. allergies to iodine-based agents

The nurses assessing a patient's heart sounds and has difficulty auscultating the first heart sound, S1. Which nursing response is most appropriate? a. listen at the base of the heart b. listen only for higher pitches sounds c. ask the patient to lay on his left side d. ask the patient to hold their breath for 15 seconds

c. ask the patient to lay on his left side *shifts the heart against the rib cage

A client is having frequent premature ventricular contractions. The nurse should place priority on assessment of which item? a. causative factors, such as caffeine b. sensation of fluttering or palpitations c. blood pressure and oxygen saturation d. precipitating factors, such as infection

c. blood pressure and oxygen saturation

A nurse cares for a patient with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations would the nurse assess? (Select all that apply.) a. Increase in urine output b. Increase in cardiac output c. Decrease in urine output d. Decrease in cardiac output

c. decrease in urine output d. decrease in cardiac output

A nurse assesses a patient with pericarditis. Which assessment finding would the nurse expect to find? a. presence of a regular gallop rhythm b. coarse crackles in bilateral lung bases c. friction rub at the left lower sternal border d. heart rate that speeds up and slows down

c. friction rub at the left lower sternal border

The nurse is reviewing an electrocardiogram rhythm strip. The P waves and QRS complexes are regular. The PR interval is 0.16 seconds, and QRS complexes measure 0.06 seconds. The overall heart rate is 64 beats per minute. Which action should the nurse take? a. check vital signs b. check laboratory test results c. monitor for any rhythm change d. notify the primary health care provider

c. monitor for any rhythm change

Which of the following symptoms would the nurse anticipate in a patient with right-sided heart failure? (select all that apply) a. pulmonary congestion b. shortness of breath c. neck vein distention d. enlarges abdominal girth e. a third heart sound

c. neck vein distention d. enlarged abdominal girth

A nurse cares for a patient with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions would the nurse implement to address this patient's concerns? a. administer oxygen therapy at 2L per nasal cannula b. provide the patient with a sleeping pill to stimulate rest c. schedule periods of exercise and rest during the day d. ask unlicensed assistive personnel to help bathe the patient

c. schedule periods of exercise and rest during the day

A nurse assesses a patient who is recovering after a left-sided cardiac catheterization. Which assessment finding requires immediate intervention? a. urinary output less than intake b. bruising at the insertion site c. slurred speech and confusion d. discomfort in the left leg

c. slurred speech and confusion *worry about clotting and possibly going to lungs, heart, or brain = risk of stroke

The nurse is reviewing the lipid panel of a male patient who has atherosclerosis. Which finding is most concerning? a. low-density lipoprotein cholesterol (LDL-C): 122mg/dL b. high-density lipoprotein cholesterol (HDL-C): 48mg/dL c. triglycerides: 198mg/dL d. cholesterol: 126mg/dL

c. triglycerides: 198 mg/dL

The nurse is watching the cardiac monitor and notices that a client's rhythm suddenly changes. There are no P waves, the QRS complexes are wide, and the ventricular rate is regular but more than 140 beats per minute. The nurse determines that the client is experiencing which dysrhythmia? a. sinus tachycardia b. ventricular fibrillation c. ventricular tachycardia d. premature ventricular contractions

c. ventricular tachycardia

A nurse evaluates prescriptions for a patient with chronic atrial fibrillation. Which medication would the nurse expect to find on this patient's medication administration record to prevent a common complication of this condition? a. soltalol (Betapace) b. atropine (Sal-Tropine) c. warfarin (Coumadin) d. lidocaine (Xylocaine)

c. warfarin (Coumadin)

A nurse is teaching a patient with type 1 diabetes about exercise. The nurse understands the patient should avoid exercise during what time? a. during colder months b. when serum glucose is less than 150 c. when ketones are present in the urine d. when emotional stressors are high for the patient

c. when ketones are present in the urine

A nurse cares for a patient with diabetes mellitus who asks, "Why do I need to administer more than one injection of insulin each day?" How would the nurse respond? a. "A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock." b. "You need to start with multiple injections until you become more proficient at self-injection." c. "A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates." d. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns."

d. "A single dose of insulin each day would not match your blood insulin levels and your food intake patterns."

A nurse cares for a patient who has hypothyroidism as a result of Hashimoto's thyroiditis. The patient asks, "How long will I need to take this thyroid medication?" How does the nurse respond? a. "You will need to take the thyroid medication until the goiter is completely gone." b. "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." c. "When blood tests indicate normal thyroid function, you can stop the medication." d. "You'll need thyroid pills for life because your thyroid won't start working again."

d. "You'll need thyroid pills for life because your thyroid won't start working again."

A client in ventricular fibrillation is about to be defibrillated. To convert this rhythm effectively, the monophasic defibrillatior machine should be set at which energy level (in joules, J) for the first delivery? a. 50 J b. 120 J c. 200 J d. 360 J

d. 360 J

The nurse knows which patient with Cushing's disease is at greatest risk for developing heart failure? a. 60 yr old with pneumonia b. 59 yr old with a history of hypertension c. 32 yr old with history of hep B infection d. 42 yr old with a serum creatinine level of 3.7mg/dL

d. 42 yr old with a serum creatinine level of 3.7mg/dL

Which priority assessment finding alerts the nurse to perform a detailed assessment of the patient's endocrine system? a. fatigue b. weight gain c. reports being cold all the time d. changes in hair texture and distribution

d. changes in hair texture and distribution

The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pads on the client's chest and before discharging the device, which intervention is a priority? a. ensure that the client has been intubated b. set the defibrillator to the "synchronize" mode c. administer an amiodarone bolus intravenously d. confirm that the rhythm is ventricular fibrillation

d. confirm that the rhythm is ventricular fibrillation

A patient had a percutaneous transluminal coronary angioplasty for peripheral arterial disease. What assessment finding by the nurse indicated that a priority outcome for this patient has been met? a. verbalizes understanding of procedure b. pain rated as 2/10 after medication c. remains on bedrest as directed d. distal pulse on affected extremity 2+/4+

d. distal pulse on affected extremity 2+/4+