Final hesi exit 1

A client with diabetes is given instructions about foot care. The nurse determines that the instructions are understood when the client states, "I will:

Break in my new shoes over the course of several weeks."

A nurse is providing postoperative care for a client one hour after the client had an adrenalectomy. Maintenance steroid therapy has not begun yet. The nurse should monitor the client for which complication?

Hypotension

A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis?

Increased serum lipids

The health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. The nurse explains that this drug:

Interferes with the synthesis of thyroid hormone

A nurse in the birthing room gives an injection of vitamin K to a newborn. The vitamin K is prescribed because it:

Promotes formation of clotting factors in the liver

A client is admitted to a medical unit with a diagnosis of Addison disease. The client is emaciated and reports muscular weakness and fatigue. Which disturbed body process does the nurse determine is the root cause of the client's clinical manifestations?

Protein anabolism

A nurse manager is providing a class on cystic fibrosis for the pediatric staff nurses. Physiological adaptations to cystic fibrosis are a result of

Pathology of mucus-secreting glands

Blood studies are being performed on a client with the potential diagnosis of hyperparathyroidism. What serum blood level should the nurse expect to be decreased when reviewing this client's hematologic studies?

Phosphorus

A nurse is providing discharge teaching for the parents of a 6-year-old child with acute laryngotracheobronchitis. What should the nurse instruct the parents to do to control symptoms at home?

Start a cool-mist humidifier close to the child.

What is the focus of the nurse's anticipatory guidance during the first trimester of pregnancy?

Physical changes of pregnancy

A nurse is reviewing the immunization schedule of an 5-month-old infant. What immunizations does the nurse expect the infant to have already received?

Rotavirus, DTaP, Haemophilus influenzae, polio, pneumococcal,

A client with malignant hot nodules of the thyroid gland has a thyroidectomy. Immediately after the thyroidectomy, the nurse's priority action for this client is to:

Place in low-Fowler position to limit edema of the neck

A primipara gives birth to an infant weighing 9 lb 15 oz (4508 g). During labor a midline episiotomy is performed and the client sustains a third-degree laceration. The client tells the nurse that her perineal area is very painful. What should the nurse consider before explaining the reason for the pain?

The anal sphincter muscle has been injured

A child who has persistent inattentive behavior is prescribed methylphenidate hydrochloride. Which behavior indicates that the child needs further treatment?

The child experiences difficulty keeping school supplies organized.O

A nurse is assessing a malnourished client with a history of cirrhosis. The client is experiencing nausea, ascites, and gastrointestinal bleeding. The primary cause of the client's ascites is a decrease in:

Plasma protein to maintain adequate capillary-tissue circulation.

A client is scheduled to have a thyroidectomy. Which medication does the nurse anticipate the health care provider will prescribe to decrease the size and vascularity of the thyroid gland before surgery?

Potassium iodide (SSKI

Propylthiouracil (PTU) is prescribed for a client diagnosed with hyperthyroidism. The client asks the nurse, "Why do I have to take this medication if I am going to get the atomic cocktail?" The nurse explains that the medication is being prescribed because it decreases the:

Production of thyroid hormones.

A client who had an above-the-knee amputation (AKA) has a pressure dressing on the end of the residual limb. The client asks, "Why do I have to have this tight dressing on my leg?" Which answer by the nurse is correct?.

It decreases the swelling of the area.

A client with acquired immunodeficiency syndrome (AIDS) comments to the nurse, "There are so many rotten people around. Why couldn't one of them get AIDS instead of me?" The nurse's best response is:.

It seems unfair that you should be so ill."

A woman who is Rh negative has a spontaneous abortion at the end of the second trimester, and the health care provider prescribes Rho(D) immune globulin (RhoGAM). The client asks the nurse, "Why do I need this drug?" What should the nurse consider before answering the client's question?

It will prevent the woman from producing antibodies.

While assessing a term infant a few hours after birth, the nurse finds a body temperature of 95.5° F. What does the nurse do in this situation?

Keep the infant in a double-walled incubator for a few hours.

A newborn who is born at 36 weeks' gestation weighs 8 lb 13 oz (3997 g). How should the nurse document this finding?

LGA and preterm

The nurse is caring for a client diagnosed with Cushing syndrome. The nurse expects that the client will exhibit:

Lability of mood

Which clinical indicators can the nurse expect when assessing a client with Cushing syndrome? Select all that apply.

Lability of mood Correct Incorrect 2 Slow wound healing

A client is admitted to the hospital for surgery for a total abdominoperineal resection. What position should the nurse encourage the client to maintain when in bed to promote perineal wound healing after surgery?

Left or right side-lying

A nurse is caring for a client who has had type 1 diabetes for 25 years. The client states, "I have been really bad for the last 15 years. I have not paid attention to my diet and have done little to control my diabetes." What signs of common complications of diabetes might the nurse expect to identify when assessing this client? Select all that apply.

Leg ulcers Correct Incorrect 2 Loss of visual acuity Correct Incorrect 3 Thick, yellow toenails Decreased sensation in the feet

A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. What should the nurse consider when formulating a response?

Less thyroid tissue is available to supply thyroid hormone after surgery.

In addition to clients who are receiving insulin for type 1 diabetes, the nurse should assess for signs and symptoms of hypoglycemia in clients who are diagnosed with:

Liver disease

What clinical indicators should a nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Weight loss Tachycardia Restlessness Exophthalmos

A client with a sucking chest wound has a large tight dressing over the site. The nurse understands that the purpose of this dressing is to:

Maintain the appropriate pressure within the chest cavity

What is the priority nursing intervention for a client during the immediate postoperative period?

Maintaining a patent airway,,

A client with type 1 diabetes consistently has high glucose levels on awakening in the morning. What should the nurse instruct the client to do to differentiate between the Somogyi effect and the dawn phenomenon?

Measure the blood glucose level between 2 AM and 4 AM.

A nurse is caring for a preterm infant with necrotizing enterocolitis (NEC). What nursing intervention is most important for this infant?

Measuring abdominal girth frequently

A nurse is caring for a client after radioactive iodine is administered for Grave's disease. What information about the client's condition after this therapy should the nurse consider when providing care?

Mildly radioactive but should be treated with routine safety precautions

A nurse is caring for a client with the clinical manifestation of hypotension associated with a diagnosis of Addison disease. Which hormone is impaired in its production as a result of this disease?

Mineralocorticoids

A nurse administers the prescribed regular insulin (Novolin R) to a client in diabetic ketoacidosis. In addition, the nurse anticipates that the intravenous (IV) solution prescribed will contain potassium to replenish potassium ions in the extracellular fluid that are being:

Moved into the intracellular fluid compartment because of the generalized anabolism induced by insulin and glucose.

A client with diabetes mellitus complains of difficulty seeing. The nurse concludes that the causative factor is:

Neovascularization of the retina

A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? Select all that apply.

Nervousness Increased appetite

Which common initial clinical effects should the nurse expect a client with multiple sclerosis to exhibit? Select all that apply.

Nystagmus Scanning speech Intention tremors

A nurse is caring for a client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply.

Obese trunk Sleep disturbance Correct Incorrect 5 Thin arms and legs

An emergency tracheotomy has been performed on a 6-year-old child with acute epiglottitis, and the child is receiving humidified air through a tracheotomy collar. What early clinical manifestations of hypoxia should alert the nurse to suction the tracheotomy?

Restlessness and increase in pulse

A nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of a pituitary tumor. What signs of Cushing syndrome does the nurse identify?

Retention of sodium and water

A client with type 2 diabetes travels frequently and asks how to plan meals during trips. The nurse's most appropriate response is:

"Choose the foods you normally do and follow your food plan wherever you are."

A client is taught how to recognize indications of a hypoglycemic reaction. Which signs and symptoms identified by the client indicate to the nurse that the teaching was effective? Select all that apply.

Fatigue Weakness Nervousness Increased perspiration

A client is taking an antithyroid medication for hyperthyroidism. The nurse provides education about serious health problems that may develop if the medication is not effective and tachycardia continues. The nurse instructs the client to seek medical attention immediately if any of the problems occur. Which should be included in the teaching? Select all that apply.

Weight gain Pedal edema

Blackwater fever occurs in some clients with malaria. For which response should the nurse assess this client?

Dark red urine

A nurse is caring for a client with an underactive thyroid gland. Which responses should the nurse expect the client to exhibit as a result of decreased levels of triiodothyronine (T3) and thyroxine (T4)? Select all that apply.

Weight gain Cold intolerance

A client in thyroid storm tells the nurse, "I know I'm going to die. I'm very sick." What is the nurse's best response?

"You must feel very sick and frightened."

A client with a tentative diagnosis of Cushing syndrome has an increased cortisol level. For what response should the nurse assess this client?

Hypernatremia

After surgery a client is to receive an antibiotic by intravenous (IV) piggyback in 50 mL of a diluent. The piggyback is to infuse in 20 minutes. The drop factor of the IV set is 15 gtts/mL. The nurse should set the piggyback to flow at how many gtts/min? Record your answer using a whole number. ___ gtts/min.

38

Which client is considered at the highest risk for a dissecting aneurysm?.

55-year-old black male with uncontrolled hypertension

A client with adrenal insufficiency reports feeling weak and dizzy, especially in the morning. What should the nurse determine is the most probable cause of these symptoms?

A hypoglycemic reaction

One statement by a breastfeeding mother that indicates that the nurse's teaching about stimulating the let-down reflex has been successful is "I will:

Apply warm packs and massage my breasts before each feeding."

What is the best nursing intervention to minimize perineal edema after an episiotomy?

Applying ice packs

The major nursing concern when caring for a client with the diagnosis of hyperthyroidism is:

Arranging for sufficient rest periods

Aspirin is prescribed for a client with rheumatoid arthritis. Which clinical indicators of aspirin toxicity should the nurse teach the client to report? Select all that apply.

Blood in the stool Correct Incorrect 4 Ringing in the ears

A client's laboratory values demonstrate an increased serum calcium level, and further diagnostic tests reveal hyperparathyroidism. For what clinical manifestations should the nurse assess this client? Select all that apply.

Cardiac dysrhythmias Correct Incorrect 5 Hypoactive bowel sounds

A client who is to begin continuous ambulatory peritoneal dialysis asks the nurse what this entails. What information should the nurse include when answering the client's question?

Constant contact is maintained between the dialysate and the peritoneal membrane.

A client who has just had an adrenalectomy is told about a death in the family and becomes very upset. The nurse notifies the health care provider about the client becoming upset. What is the primary reason the nurse chose to notify the health care provider?

Despite steroid therapy, the ability to cope with stress will be decreased

Fludrocortisone (Florinef) is prescribed for a client with adrenal insufficiency. Which responses to the medication should the nurse teach the client to report? Select all that apply.

Edema Correct Incorrect 2 Rapid weight gain

The nurse is providing care for a client with small-cell carcinoma of the lung that develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What clinical findings correspond with the secretion of antidiuretic hormone (ADH)? Select all that apply.

Edema Hyponatremia

A nurse plans to teach the signs of rejection to a client who just had a transplanted kidney. What sign of rejection should the nurse include?

Elevated blood pressure

A nurse is caring for a client who is admitted to the hospital with the diagnosis of primary hyperparathyroidism. Which action should be included in this client's plan of care?

Ensuring a large fluid intake

A client with a brain tumor develops a urine output of 300 mL/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform for this client?

Evaluate urine specific gravity.

A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include that will decrease the risk of complications? Select all that apply.

Examining the feet daily Wearing well-fitting shoes Performing regular exercise

A nurse is assessing a client with a diagnosis of diabetes insipidus. For which signs indicative of diabetes insipidus should the nurse assess the client? Select all that apply.

Excessive thirst Dry mucous membranes Decreased urine specific gravity

The nurse is providing teaching to a client who recently has been diagnosed with type 1 diabetes. The nurse reinforces the importance of monitoring for ketoacidosis. What are the signs and symptoms of ketoacidosis? Select all that apply.

Excessive thirst Fruity-scented breath Confusion

A client visits the clinic because of concerns about insomnia and recent weight loss. A tentative diagnosis of hyperthyroidism is made. In addition to these changes, the nurse further assesses this client for:

Fatigue

The nurse is planning discharge instructions for a client who had a thyroidectomy. For which signs of surgically induced hypothyroidism should the nurse alert the client? Select all that apply.

Fatigue Dry skin

A client is admitted to the hospital with diabetic ketoacidosis. The nurse identifies that the elevated ketone level present with this disorder is caused by the incomplete oxidation of:

Fats

Using Nägele's rule, determine the estimated date of birth (EDB) for a client whose last menstrual period started on May 10.

February 17

A nurse is caring for a postoperative client who had general anesthesia during surgery. What independent nursing intervention may prevent an accumulation of secretions?

Frequent changes of position.

A nurse is assessing a female client with Cushing syndrome. Which clinical findings can the nurse expect to identify? Select all that apply.

Hirsutism Buffalo hump

A nurse is assessing a client with Cushing syndrome. Which signs should the nurse expect the client to exhibit? Select all that apply.

Hirsutism Round face Buffalo hump

A nurse is performing a physical assessment of a pregnant woman. What factor in the client's history increases the risk for abruptio placentae?

Hypertension

A client with a diagnosis of acquired immunodeficiency syndrome (AIDS) has a protozoal infection and is receiving pentamidine (NebuPent). The nurse should monitor the client for which common side effects? Select all that apply.

Hypoglycemia Decreased blood pressure

A nurse is caring for a client who was admitted to the hospital with a diagnosis of Addison disease. The nurse should assess the client for what signs related to this disorder?

Hypoglycemia and hypotension

A client is admitted to the hospital with a potential diagnosis of excess antidiuretic hormone. For which clinical indicator should the nurse monitor this client?

Hyponatremia

A client with type 2 diabetes tells the nurse, "I take guaifenesin (Robitussin) cough syrup when I have a cold." The nurse teaches the client to:

Include the glucose in the cough syrup when calculating daily carbohydrate allowance

A nurse is assisting a health care provider with an edrophonium (Tensilon) test to determine whether a client has myasthenia gravis. What should the nurse do to prepare for the test?.

Insert a venous access device for medication.

During a teaching session about insulin injections, a client asks the nurse, "Why can't I take the insulin in pills instead of taking shots?" What is the nurse's best response?

Insulin is destroyed by gastric juices, rendering it ineffective."

Which information from the client's history does the nurse identify as a risk factor for developing osteoporosis?

Receives long-term steroid therapy

A client with diabetes states, "I cannot eat big meals; I prefer to snack throughout the day." What information should the nurse include in a response to this client's statement?

Regulated food intake is basic to control.

A client has a thyroidectomy for cancer of the thyroid. To evaluate for nerve injury that may be the result of surgery-related trauma, the nurse assesses the client's ability to:

Speak

A client admitted to the emergency department has ketones in the blood and urine. Which situation associated with this physiologic finding should be the nurse's focus when collecting additional data about this client?

Starvation

A client newly diagnosed with type 2 diabetes is receiving glyburide (Micronase) and asks the nurse how this drug works. The nurse explains that glyburide:

Stimulates the pancreas to produce insulin

A mother brings her 6-year-old child to the pediatric clinic, stating that the child has not been feeling well, is weak and lethargic, and has a poor appetite, headaches, and smoky-colored urine. What additional information should the nurse obtain that will aid diagnosis?

Strep throat in the past 2 weeks

While hospitalized, a client with diabetes is observed picking at calluses on the feet. The nurse should immediately:

Teach the client the importance of effective foot care

Hydrocortisone (Cortef) is prescribed for a client with Addison disease. Before discharge, the nurse teaches the client about this medication. What did the nurse include as a therapeutic effect of the drug?

Supports a better response to stress

Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Tachycardia Exophthalmos

A client has had a resection of an aldosterone-secreting tumor of an adrenal gland. The client says to the nurse, "It will be good for me to return to work soon." Based on an understanding of the health problem, the nurse should:

Tell the client that returning to work is okay because the body has two adrenal glands; the tumor was on just one of the glands.

A school-aged child with cystic fibrosis has recurrent episodes of bronchitis, and the parents ask the nurse why this happens. What reason should the nurse include in the reply?

Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria.

On the third postoperative day after a subtotal thyroidectomy for a tumor, a client complains of a "funny, jittery feeling." On the basis of this statement, the nurse's best action is to:

Test for Chvostek's and Trousseau's signs and notify the health care provider of the complaints

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse do to confirm that the membranes have ruptured?

Test the leaking fluid with Nitrazine paper

How should a nurse screen the newborn of a diabetic mother for hypoglycemia?

Testing heel blood with the use of a glucose-oxidase strip

A client who has just had an adrenalectomy is told about a death in the family and becomes very upset. What concern about the client requires the nurse to notify the health care provider?

There is a decreased ability to handle stress despite steroid therapy.

A client with type 1 diabetes who has been adhering to a prescribed insulin regimen is admitted to the hospital in ketoacidosis. Which factor may have precipitated the ketoacidosis?

Upper respiratory infection

When assessing the laboratory values of a client with type 2 diabetes, the nurse expects the results to reveal:

Urine negative for ketones and glucose in the blood

Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes?

Urine negative for ketones and hyperglycemia.

A toddler is admitted to the emergency department with a diagnosis of acute spasmodic laryngitis. After the spasms subside, the child is ready to be discharged. What should the nurse teach the parents to do at home to help prevent another croup episode?

Use a cool mist vaporizer in the child's room

A client experiencing thyrotoxic crisis tells the nurse, "I know I'm going to die. I'm very sick." Which is the best response by the nurse?

You must feel very sick and frightened."

The nurse is teaching a diabetic client about the advantages of using an insulin pump. What information should the nurse include? Select all that apply.

can improve A1c levels Clients can exercise without eating more carbohydrates

A health care provider prescribes steroid therapy for a 4-year-old child who has nephrotic syndrome. What goal of this treatment does the nurse explain to the child's parents?

stimulates diuresis

Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. How should the nurse interpret these data?

these findings indicate that the infant may have a pneumothorax, and the health care provider should be contacted immediately

A 40-year-old male is prescribed Metformin XL (Glucophage) to control his type 2 diabetes mellitus. Which statement made by this client indicates the need for further education?

will stop taking Metformin for 24 hours before and after having a test involving dye."

Because of multiple physical injuries and emotional concerns, a hospitalized client is at high risk to develop a stress ulcer (Curling's). The nurse recalls that stress ulcers usually are evidenced by:

A sudden massive hemorrhage

A client is admitted with a head injury. The nurse identifies that the client's urinary retention catheter is draining large amounts of clear, colorless urine. What does the nurse identify as the most likely cause?

Inadequate antidiuretic hormone (ADH) secretion

After a surgical thyroidectomy a client exhibits carpopedal spasm and some tremors. The client complains of tingling in the fingers and around the mouth. What medication should the nurse expect the primary health care provider to prescribe after being notified of the client's adaptations?

Calcium gluconate

An 11 year-old girl is admitted with enlarged supraclavicular lymph nodes, fatigue, and low-grade fever. She also has a persistent nonproductive cough. In light of these findings, the nurse knows to gear education toward preparation for:

Computed tomography and lymph node biopsy

The nurse is using the Silverman-Anderson index to assess an infant with respiratory distress and determines that the infant is demonstrating marked nasal flaring, an audible expiratory grunt, and just visible intercostal and xiphoid retractions. Using this scale, which score should the nurse assign?

D. 8

A client has a glycosylated hemoglobin measurement of 6%. What should the nurse conclude about this client when planning a teaching plan based on the results of this laboratory test?

Has followed the treatment plan as prescribed

During the transition phase of labor, a client complains of tingling and numbness in her fingers and tells the nurse that she feels like she is going to pass out. What action should the nurse take?

Have her cup both hands over her nose and mouth while breathing.

A nurse is caring for a client who had an adrenalectomy. For what clinical response should the nurse monitor while steroid therapy is being regulated?

Hypotension

A client is admitted to the hospital for a subtotal thyroidectomy. When discussing postoperative drug therapy with the client, the nurse should teach the client to:

Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone

A nurse is monitoring for clinical manifestations of infection in a client with a diagnosis of Addison disease. Which body mechanism related to infectious processes does the nurse conclude is impaired as a result of this disease?

Stress response

Which position does the nurse teach the client to avoid when she experiences back pain during labor?

Supine position

When assessing a client with Graves disease, the nurse expects to identify:

Weight loss, exophthalmos, and restlessness

A 5-year-old child is admitted to the pediatric intensive care unit with a diagnosis of acute asthma. A blood sample is obtained to measure the child's arterial blood gases. What finding does the nurse expect?

increased carbon dioxide level

A nurse is assessing a client with hypothyroidism. Which clinical manifestations should the nurse expect the client to exhibit? Select all that apply.

Cool skin Constipation Correct Incorrect 4 Periorbital edema Correct Incorrect 5 Decreased appetite

A client with acquired immunodeficiency syndrome (AIDS) is receiving a treatment protocol that includes a protease inhibitor. When assessing the client's response to this drug, which common side effect should the nurse expect?

Diarrhea

A client with hyperthyroidism refuses radioactive iodine therapy and a subtotal thyroidectomy is scheduled. The nurse reviews the preoperative plan of care and questions which prescription?

Drugs to increase the blood pressure

When preparing a client for discharge after a thyroidectomy, the nurse teaches the signs of hypothyroidism. The nurse evaluates that the client understands the teaching when the client says, "I should call my health care provider if I develop:

Dry hair and an intolerance to cold."

A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestations should the nurse expect when assessing this client? Select all that apply.

Dry skin Brittle hair

A nurse is assessing a client with diabetic ketoacidosis. Which clinical manifestations should the nurse expect? Select all that apply.

Dry skin Correct Incorrect 2 Abdominal pain Correct Incorrect 3 Kussmaul respirations

A client at 36 hours' postpartum is being treated with subcutaneous enoxaparin (Lovenox) for deep vein thrombosis of the left calf. Which client adaptation is of most concern to the nurse who is monitoring the client?

Dyspnea

The nurse is assessing a client with hyperthyroidism. Which clinical indicators are consistent with this diagnosis? Select all that apply.

Emotional lability Dyspnea on exertion Hyperactive deep tendon reflexes

A nurse may find that, for optimum nutrition, a client with a cerebrovascular accident (also known as "brain attack") needs assistance with eating. What should the nurse do?

Encourage the client to participate in the feeding process.

A client has a kidney transplant. The nurse should monitor for which signs associated with rejection of the transplant? Select all that apply.

Fiebre Oliguria Weight gain

A nurse is caring for a newly admitted client with a diagnosis of Cushing syndrome. Why should the nurse monitor this client for clinical indicators of diabetes mellitus?

Glucocorticoids accelerate the process of gluco-neogenesis.

The nurse is teaching a prenatal class to expectant mothers in their first trimester of pregnancy. In addition to discussing the need for 0.6 mg/day of folic acid replacement, which dietary choice that is high in folic acid should the nurse recommend?

Half cup of cooked spinach

The nurse assesses a married 35-year-old client who is to undergo a tubal ligation to determine the client's possible emotional response to the procedure. The factor in the history that contributes most to the healthy resolution of any emotional problem associated with sterilization is that the client:

Has a son and daughter and feels that her family is complete

A nurse who is caring for a 7-year-old child with acute glomerulonephritis assesses the child for cerebral complications. What signs and symptoms indicate cerebral involvement?

Headache, drowsiness, and vomiting

A client with an aldosterone-secreting adenoma is scheduled for surgery to remove the tumor. The client asks what will happen if surgery is canceled. The nurse bases a response on the fact that:

Heart and kidney damage may occur if the tumor is not removed

The nurse expects the diagnostic studies of a client with Cushing syndrome to indicate:

High levels of 17-ketosteroids in a 24-hour urine test

A client is admitted to the hospital with the diagnosis of cancer of the thyroid and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period?

Hoarseness and airway obstruction may result from laryngeal nerve damage.

A client with Addisonian crisis exhibits severe manifestations of glucocorticoid and mineralocorticoid deficiencies. Which responses should the nurse expect the client to exhibit? Select all that apply.

Hyperkalemia Correct Incorrect 4 Hyponatremia Correct Incorrect 5 Postural hypotension

A client with human immunodeficiency virus (HIV)-associated Pneumocystis jiroveci pneumonia is to receive pentamidine isethionate (Pentam 300) intravenously (IV) once daily. The nurse should monitor the client for the side effect of:

Hypoglycemia

A client is admitted to the hospital for an adrenalectomy. The nurse is providing postoperative care before the client's replacement steroid therapy is regulated fully. The nurse should monitor the client for:

Hypotension

Immediately after a bilateral adrenalectomy a client is receiving corticosteroids that are to be continued after discharge from the hospital. The nurse evaluates a need for further teaching when the client states:

I am glad that I only have to take the medication once a day."

A client is hospitalized with a tentative diagnosis of pancreatic cancer. On admission the client asks the nurse, "Do you think I have anything serious, like cancer?" What is the nurse's best reply?

I don't know if you do; let's talk about it."

The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is uniquely related to heart failure?.

I have trouble breathing when I climb a flight of stairs."

A client with type 2 diabetes is admitted to the ambulatory surgery unit for elective cataract surgery. Before surgery the client asks the nurse, "How will my diabetes be managed while I am here?" The best response by the nurse is:

I'm not quite certain I understand what you are asking."

A client is diagnosed as having type 2 diabetes. A priority teaching goal is, "The client will be able to:

Identify pending hypoglycemia or hyperglycemia

A nurse develops a teaching plan for a client with rheumatoid arthritis. What should the nurse include in the plan about ways to reduce joint stress?

If experiencing pain after one to two hours of activity, actively take measures to address the pain

During an acquired immunodeficiency syndrome (AIDS) education class a client states, "Vaseline works great when I use condoms." Which conclusion about the client's knowledge of condom use can the nurse draw from this statement?

Ignorance related to correct condom use

A client newly diagnosed as having type 1 diabetes is taught to exercise on a regular basis primarily because exercise has been shown to:

Improve the cellular uptake of glucose

A nurse is caring for a client after a thyroidectomy. For which signs of thyroid storm should the client be monitored? Select all that apply.

Increased heart rate Increased temperature

A nurse is caring for a client who had a hypophysectomy. For which complication specific to this surgery should the nurse assess the client for early clinical manifestations?

Increased intracranial pressure

A client with diabetes asks how exercise will affect insulin and dietary needs. The nurse should respond, "Exercise:

Increases the need for carbohydrates and decreases the need for insulin."

Since giving birth six months ago, a woman has breastfed her infant. The woman becomes hysterical after learning that her husband has been seriously injured in an automobile accident. Culturally this woman believes that emotional stress while breastfeeding can "sour the milk," and she indicates that she must wean her infant immediately. What should the nurse do?

Instruct the mother about formula feeding.

The nurse is caring for a client with diabetes mellitus. The nurse recalls that the primary fluid shift that occurs with this condition is:

Intracellular to intravascular because of hyperosmolarity

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis. What is the initial intervention that the nurse should expect the health care provider to prescribe for this client?

Intravenous (IV) fluids

Preparation of a client for a subtotal thyroidectomy may include the administration of potassium iodide solution. The client refuses to take the medication. What explanation should the nurse give as to why this medication should be taken?

It will reduce the risk of hemorrhage during surgery.

What does the nurse do to elicit the Moro reflex during a newborn assessment?

Jars the infant's bassinet suddenly but gently

A client's last menstrual period was on September 4. According to Nägele's rule, what is the expected date of birth?

June 11

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct?

Keep the drainage system lower than the level of the client's chest

A client is receiving magnesium sulfate therapy for severe preeclampsia. What initial sign of toxicity should prompt the nurse to intervene?

Lack of the knee-jerk reflex

A nurse is caring for an older client who had non-insulin dependent diabetes for 15 years that progressed to insulin dependent diabetes 2 years ago. What common complications of diabetes should the nurse assess for when examining this client? Select all that apply.

Leg ulcers Loss of visual acuity Prolonged capillary refill in the toes Decreased sensation in the lower extremities

nurse is caring for an older client who had non-insulin dependent diabetes for 15 years that progressed to insulin dependent diabetes 2 years ago. What common complications of diabetes should the nurse assess for when examining this client? Select all that apply.

Leg ulcers Loss of visual acuity Prolonged capillary refill in the toes Decreased sensation in the lower extremities

A client is diagnosed as having type 2 diabetes, and the health care provider prescribes an oral hypoglycemic. The nurse should include in the teaching plan that people taking oral hypoglycemics:

May subconsciously relax dietary rules to gain a sense of control

The client is admitted to the hospital with a large goiter, and a thyroidectomy is performed. What should the nurse do during the first four hours after the surgery? Select all that apply

Monitor for stridor or dyspnea . Assess the sides and back of the client's neck for evidence of bleeding.

A client who is 60 pounds more than the ideal body weight is admitted to the hospital with a diagnosis of type 1 diabetes. Which concept should the nurse include in teaching about diabetes when discussing strategies to lose weight?

Obesity leads to insulin resistance

A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply.

Oliguria Correct Incorrect 2 Seizures Correct Incorrect 3 Vomiting

A client with small cell carcinoma of the lung develops the syndrome of inappropriate antidiuretic hormone (SIADH). What signs should the nurse expect to observe? Select all that apply.

Oliguria Seizures Vomiting

A nurse is caring for a client with myxedema who has undergone abdominal surgery. What should the nurse consider when administering opioids to this client?

One-third to one-half the usual dose should be prescribed.

A mother is concerned that her newborn will be exposed to communicable diseases when she goes home. While teaching the mother ways to decrease the risk of infection, what type of immunity should the nurse explain was transferred to her baby through the placenta?

Passive natural

The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L. When monitoring the ECG tracing, the nurse expects to observe:

Peaked T waves and widened QRS complexes

A nurse is caring for a client who is receiving total parenteral nutrition. Which responses indicate that the client is experiencing hyperglycemia? Select all that apply.

Polyuria Polydipsia

A client with hyperthyroidism is being treated with propylthiouracil (PTU). What instruction should the nurse plan to include in the teaching plan regarding this drug? Select all that apply.

"1/Avoid abrupt discontinuation of the medication." 2/Monitor your weight, pulse, and mood routinely." "3/Report side effects, such as sore throat, fever, joint pain, or oral lesions."

The parents of a 6-year-old child tell a nurse at the pediatric clinic that their child is weak and lethargic, has headaches, has no appetite, and has dark, cloudy urine. The nurse suspects acute poststreptococcal glomerulonephritis (APSGN). What should the nurse ask the mother?

"Did your child have a sore throat during the past 3 weeks?"

A school nurse informs the mother of an 11-year-old girl that her daughter has been giving her lunch to friends and buying cookies and cola at lunchtime. The mother asks the nurse how best to solve this problem. How should the nurse respond?

"Have her help you plan nutritious meals that include her favorite foods."

A nurse teaches a client with asthma about her illness during pregnancy. Which statement by the client indicates that the nurse's teaching has been effective?

"I can use my albuterol inhaler if it's absolutely necessary."

The school nurse is discussing issues related to premarital sex with a group of adolescents taking a health education course. The students are asked to write an essay on what they have learned about preventing pregnancy. Which comment alerts the nurse to have a private discussion with the student?

"I can't get pregnant if I have sex during my period."

After a client has a spontaneous abortion at 12 weeks' gestation, the nurse notes that she and her partner are visibly upset. The partner has tears in his eyes, and the client is sobbing quietly with her face turned to the wall. At this time, what is the nurse's most therapeutic statement?

"I'll be here if you want to talk."

On her first visit to the neonatal intensive care unit to see her preterm newborn daughter, the mother stands 2 feet away and does not touch the infant. The mother's only comment to the nurse is, "She looks so fragile. Do you think she'll make it?" What is the most appropriate response by the nurse?

"It's understandable that she looks fragile to you. What have you learned about her condition?"

After receiving a diagnosis of placenta previa, the client asks the nurse what this means. What is the nurse's best response?

"The placenta is implanted in the lower uterine segment, and it's covering part or all of the cervical opening."

A 37-year-old woman is admitted to the unit with severe menorrhagia. During assessment the nurse learns that she has a history of fibroids, menorrhagia, pelvic pain, and depression. The client has been undergoing hormone therapy in hopes of easing the symptoms and reducing the size of the fibroids, without success. The lab reports hemoglobin and hematocrit readings of 6.8 and 20.2, respectively. The client begins to sob and cries, "I don't know what to do—the doctor is recommending a hysterectomy, but I haven't had children yet!" What is the best response by the nurse?

"This must be so difficult for you. Children are really important to you?"

An infant was born 30 minutes ago. The nurse is preparing an injection of vitamin K for the infant. Which dosage and route will the nurse use?

0.5 to 1.0 mg given intramuscularly

The registered nurse managing the care of four clients is determining individual priorities. Place the following clients in order of priority, with 1 as the highest priority.

1.A depressed client who shares with her roommate that she is "very happy today" 2.A manic client who has spent the last 8 hours refusing liquids and pacing around the unit 3.A client whose auditory hallucinations are telling her, "They're going to get you." 4.A cognitively impaired older adult who believes that her dead husband will visit today

An older client is diagnosed with Alzheimer disease. For which clinical manifestations should the nurse assess the client? Select all that apply..

1/Loss of recent memory, 2/Perceptual disturbances, 3/Difficulty learning something new

A nurse is monitoring a client's fasting plasma glucose (FPG) level. At which FPG level should the nurse identify that the client has prediabetes?

100 mg/dL

A client with type 1 diabetes self-administers NPH insulin (Novolin N) every morning at 8:00 AM. The nurse concludes that the client understands the action of this insulin when the client says, "I should be alert for signs of hypoglycemia between:

12 PM and 8 PM."

A prescription is written for famotidine (Pepcid) 20 mg intravenous piggyback (IVPB) every 12 hours. The vial is labeled 10 mg/1 mL. How many milliliters should the nurse administer? Record the answer using a whole number. ___ mL

2

A woman at 36 weeks' gestation is admitted to the hospital to receive a tocolytic medication in an attempt to stop labor. In addition, betamethasone (Celestone) is prescribed to enhance fetal lung maturity. The prescription reads: "Administer betamethasone 12 mg IM daily for 3 days." The betamethasone comes in a vial labeled "6 mg/mL." How many milliliters should the nurse administer each day? Record your answer using a whole number. __OJO

2 ML

A client with type 1 diabetes self-administers Novolin N insulin every morning at 8 AM. The nurse evaluates that the client understands the action of the insulin when the client says, "I should be alert for signs of hypoglycemia between:

2 PM and 8 PM."

A client is admitted for treatment of partial- and full-thickness burns of the entire right lower extremity and the anterior portion of the right upper extremity. Performing an immediate appraisal, using the Rule of Nines, what is the percent of body surface area burned?.

22.5%

A nurse is reviewing the history and physicals of several clients from the clinic who are taking rifampin (Rifadin) for the treatment of tuberculosis. Which client presents a specific concern for the nurse?

26-year-old taking oral contraceptives

The nurse is teaching a client newly diagnosed with diabetes about the importance of glucose monitoring. Which of the following blood glucose levels should the nurse identify as hypoglycemia?

58 mg/dL

On the third postpartum day, the nurse enters the room of a client who had an unexpected cesarean birth and finds her crying. The client says, "I know my baby is fine, but I can't help crying. I wanted natural childbirth so much. Why did this have to happen to me?" The nurse responds knowing that:

A woman's self-concept may be negatively affected by a cesarean birth, and the client's statement may reflect this.

A nurse is caring for a client admitted to the hospital for diabetic ketoacidosis. Which clinical findings related to this event should the nurse document in the client's clinical record? Select all that apply.

Acetone breath Decreased arterial carbon dioxide level

A nurse is caring for a client with diabetes who is scheduled for a radiographic study requiring contrast. Which should the nurse expect the health care provider to prescribe?

Acetylcysteine (Acetadote) before the test

A client with diabetes experiences tremors, pallor, and diaphoresis. What should the nurse consider is a possible cause of these clinical manifestations?

Aerobic exercise

An obese client with type 2 diabetes asks about the intake of alcohol or special "dietetic" food in the diet. The nurse teaches the client that:

Alcohol can be consumed, with its calories counted in the diet

A child is diagnosed with hepatitis A. The client's parent expresses concern that the other members of the family may get hepatitis because they all share the same bathroom. The nurse's best reply is:

All family members, including your child, need to wash their hands after using the bathroom."

A nurse is caring for a client with a tentative diagnosis of pheochromocytoma who is receiving chlorpromazine (Thorazine). A 24-hour urine specimen to assess the presence of vanillylmandelic acid (VMA) is prescribed to assist in the confirmation of the diagnosis. What information should the nurse include in the client teaching regarding this test? Select all that apply.

All urine excreted over the 24-hour period must be saved and refrigerated. Correct Incorrect 5 Avoid coffee, chocolate, and citrus fruit for three days before and during the test.

The nurse is assessing a client with hyperthyroidism. For which signs and symptoms should the nurse assess the client? Select all that apply.

Amenorrhea Flushed appearance Short attention span

A nurse is caring for an alert client who has diabetes and is receiving an 1800-calorie American Diabetic Association diet. The client's blood glucose level is 30 mg/dL. The healthcare provider's protocol calls for treatment of hypoglycemia with 15 g of a simple carbohydrate. The nurse should:

Ask the client to ingest one tube of glucose gel

A client with type 1 diabetes receives Humulin R insulin in the morning. Shortly before lunch the nurse identifies that the client is diaphoretic and trembling. What is the nurse's most appropriate action?

Assess the client's blood glucose level

The nurse provides postoperative care to the client following subtotal thyroidectomy by: Select all that apply.

Assessing for frequent swallowing Ambulating the client the evening of surgery Assessing for facial spasms, apprehension, or tingling of the lips, fingers, or toes Ensuring that oxygen, suction equipment, and a tracheosomy tray are at the bedside

A client with the diagnosis of Cushing syndrome has the following laboratory results: Na (sodium) 149 mEq/L; K (potassium) 3.2 mEq/L; Hb (hemoglobin) 17 g/dL; and glucose 90 mg/dL. What should the nurse teach the client? Select all that apply.

Avoid foods high in salt. Eat foods high in potassium.

The nurse teaches a client with exophthalmos how to reduce discomfort and prevent corneal ulceration. The nurse concludes that the teaching is understood when the client states, "I should:

Avoid using a sleeping mask at night."

A client with type 1 diabetes of long duration takes Novolin 70/30 (combination of Novolin N 70% and Novolin R 30%) every morning. At 11:30 AM, before eating lunch, the client is admitted to the emergency department with an acute myocardial infarction. At 1:30 PM, the client's serum glucose level drops to 30 mg/dL, and insulin coma is diagnosed. The nurse concludes that the reason for the development of acute hypoglycemia is that:

Because the client is taking insulin shots rather then an oral antidiabetic, the client's glucose level dropped more quickly

Which physiological responses should a nurse expect when assessing a client with hyperthyroidism? Select all that apply.

Blurred vision Increased appetite Correct Incorrect 5 Widened pulse pressure

For which client response should the nurse monitor when assessing for complications of hyperparathyroidism?

Bone pain

A pregnant client with severe preeclampsia is receiving IV magnesium sulfate. What should the nurse keep at the bedside to prepare for the possibility of magnesium sulfate toxicity?

Calcium gluconate

The nurse tells a pregnant woman in labor that she must avoid lying on her back. The nurse bases this instruction on the information that the supine position primarily is avoided because it can:

Cause decreased placental perfusion

A client in the birthing suite has spontaneous rupture of the membranes, after which a prolapsed cord is identified. The nurse calls for help and with a sterile gloved hand moves the fetal head off the cord. What should the nurse anticipate?

Cesarean birth

Six weeks after discharge a client returns to the clinic for her postpartum checkup. While at the clinic, the client seeks advice on preventing toxic shock syndrome. She states that she uses tampons. What should the nurse instruct the client to do?

Change the tampon about every 4 hours

What should the nurse do when collecting a 24-hour urine specimen?

Check to verify if a preservative is needed.

A nurse is caring for a client who just returned from the postanesthesia care unit after having a thyroidectomy. Which action has priority during the first 24 hours after surgery when the nurse is concerned about thyroid storm?

Checking vital signs every two hours after they stabilize

A nurse teaches a client with type 1 diabetes about the treatment of hypoglycemia. If the teaching is effective, which foods does the client identify to manage hypoglycemia?

Cheese sandwich and sugar

A client's problem with ineffective control of type 1 diabetes is pinpointed as a sudden decrease in blood glucose level followed by rebound hyperglycemia. What should the nurse do when this event occurs?

Collaborate with the health care provider to alter the insulin prescription.

A nurse is caring for two clients newly diagnosed with diabetes. One client has type 1 diabetes and the other client has type 2 diabetes. The nurse determines that the main difference between newly diagnosed type 1 and type 2 diabetes is that in type 1 diabetes:

Complications are not present at the time of diagnosis.

The nurse provides care to the client with diabetes insipidus (DI) following head injury by: Select all that apply.

Providing adequate fluids within easy reach Assessing for and reporting changes in neurological status Correct Incorrect 5 Monitoring for constipation, weight loss, hypotension, and tachycardia

A nurse mixes a short-acting and an intermediate-acting insulin in the same syringe to administer to a client with diabetes. List the actions in the order the nurse should perform them.

Put air into the intermediate-acting insulin vial. Put air into the short-acting insulin vial. Withdraw the prescribed amount of short-acting insulin. Withdraw the prescribed amount of intermediate-acting insulin. Don a pair of clean gloves.

A client with a tentative diagnosis of myasthenia gravis is scheduled to receive edrophonium (Enlon) to confirm the diagnosis. What response should the nurse anticipate will confirm myasthenia gravis?.

Rapid but brief symptomatic improvement

A nurse has administered sublingual nitroglycerine. Which parameter should the nurse use to determine the effectiveness of sublingual nitroglycerin?

Relief of anginal pain

A client who has type 1 diabetes is admitted to the hospital for major surgery. Before surgery the client's insulin requirements are elevated but well controlled. Postoperatively, the nurse anticipates that the client's insulin requirements will:

Remain elevated

A client who has acromegaly and insulin-dependent diabetes undergoes a hypophysectomy. The nurse identifies that further teaching about the hypophysectomy is necessary when the client states, "I know I will:

Require larger doses of insulin than I did preoperatively."

A client is admitted to the hospital for an adrenalectomy. When the nurse teaches the client about the prescribed medications, the nurse emphasizes that:

Salt intake may have to be restricted while taking the medications

The nurse is caring for an older client who is admitted to the hospital with a diagnosis of type 2 diabetes. The nurse recalls that older adults with type 2 diabetes:

Seldom develop ketoacidosis

A nurse anticipates that a preschooler will perceive death as:

Separation that is reversible

What is the most important test the nurse should check to determine whether a transplanted kidney is functioning?

Serum creatinine level

A nurse evaluates that a client with diabetes understands the teaching about the treatment of hypoglycemia when the client says, "If I become hypoglycemic I initially should eat:

Sugar and a slice of bread."

A nurse is teaching a client with type 1 diabetes about assessing for signs and symptoms of hypoglycemia as a result of excessive insulin. For what response should the nurse instruct the client to monitor in addition to nervousness and hunger?

Sweating

A nurse is caring for a 26-year-old client recently diagnosed with human immunodeficiency virus (HIV). The client needs an update on immunizations and asks which ones are needed. Which vaccines are required to comply with the recommended immunization schedule for a client with HIV?

Tetanus, hepatitis B, influenza, and pneumococcal vaccines

n caring for the client with Burr holes for a subdural hematoma postoperatively on day 2, the nurse notes the client has an increased temperature to 101.3 F°. The nurse understands:.

The client is exhibiting signs of an infection and the health care provider needs to be notified.

Client teaching is an important part of the perinatal nurse's role. Which factor has the greatest influence on successful teaching of the pregnant client?

The client's investment in what is being taught

A client is learning alternate site testing (AST) for glucose monitoring. Which client statement indicates to the nurse that additional teaching is necessary?

The fingertip is preferred for glucose monitoring if hyperglycemia is suspected."

A 7-year-old child is brought to the emergency department with a puncture wound on the sole. It is determined that the child's history of immunizations is uncertain and tetanus immune globulin and tetanus vaccine are prescribed and administered. What is the priority reason for using tetanus immune human globulin instead of tetanus antitoxin?

The risk for an anaphylactic reaction is less.

A client with diabetes asks the nurse whether the new forearm stick glucose monitor gives the same results as a fingerstick. What is the nurse's best response to this question?

There is no difference between readings."

A client who has had a subtotal thyroidectomy does not understand how hypothyroidism can develop when the problem was initially hyperthyroidism. The nurse bases a response on the fact that:

There may not be enough thyroid tissue to supply adequate thyroid hormone

A client at 7 weeks' gestation tells a nurse in the prenatal clinic that she is sick every morning with nausea and vomiting and adds that she does not think she can tolerate it throughout her pregnancy. The nurse assures her that this is a common occurrence in early pregnancy and will probably disappear by the end of the:

Third month

The nurse provides education related to manifestations of hyperglycemia to a client with type 1 diabetes. Which signs and symptoms identified by the client indicate that the teaching was effective? Select all that apply.

Thirst Fruity breath odor Excessive urination

A client is diagnosed with hyperthyroidism and is experiencing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? Select all that apply.

Use tinted glasses. Elevate the head of the bed 45 degrees. Tape eyelids shut at night if they do not close.

A client gives birth vaginally, with a midline episiotomy, to an infant who weighs 8 lb 13 oz (4000 g). An ice pack is applied to the perineum to ease the swelling and pain. The client complains, "This pain in my vagina and rectum is excruciating, and my vagina feels so full and heavy." What does the nurse suspect as the cause of the pain?

Vaginal hematoma

The nurse assures a breastfeeding mother that one way she will know that her infant is getting an adequate supply of breast milk is if the infant gains weight. What behavior does the infant exhibit if an adequate amount of milk is being ingested?

Voids six or more times a day

A client is admitted with a diagnosis of Cushing syndrome. For which clinical manifestations should the nurse observe when assessing this client? Select all that apply.

Weakness Correct Incorrect 3 Hypertension Correct Incorrect 4 Truncal obesity

A client on prolonged cortisone therapy for adrenal insufficiency is being discharged. Which side effects should the nurse teach the client and family to expect? Select all that apply.

Weakness Correct Incorrect 4 Moon face Correct Incorrect 5 Weight gain

Which is the best advice the nurse can give regarding foot care to a client diagnosed with diabetes?

Wear synthetic fiber socks when exercising

After surgical clipping of a cerebral aneurysm, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which manifestations of excessive levels of ADH should the nurse assess the client? Select all that apply.

Weight gain Hyponatremia

When obtaining the history of a client recently diagnosed with type 1 diabetes, the nurse expects to identify the presence of:

Weight loss

What change in blood pressure (BP) should the nurse anticipate after a client has an aldosteronoma surgically removed?

Gradually return to expected levels for an adult

A nurse teaches a postpartum client how to care for her episiotomy at home. What statement indicates to the nurse that the client understands the priority instruction?

"I need to continue perineal care after I go to the bathroom until everything is healed."

A client with type 1 diabetes who is at 39 weeks' gestation is admitted to the high-risk maternity unit. The client tells the nurse that her diabetes is under control and that she doesn't understand why she must be hospitalized. What is the best response by the nurse?

"The risk for fetal complications is highest after the 36th week of gestation."

A postpartum client tells the nurse that she wishes to breastfeed. When the nurse brings her newborn to be breastfed, the client asks whether she may drink a small glass of wine to help her relax. How should the nurse respond?

"You seem a little tense. Tell me how you feel about breastfeeding."

A client, admitted to the hospital with a fractured hip, is scheduled for surgery for a total hip replacement. In which position should the nurse place the client's affected limb after surgery?,

Abduction and extension.

A nurse is taking the health history of a client who is to have surgery in one week. The nurse identifies that the client is taking ibuprofen (Advil) for discomfort associated with osteoarthritis and notifies the health care provider. Which drug does the nurse expect will most likely be prescribed instead of the Advil?.

Acetaminophen (Tylenol)

The nurse is providing care to a client who is being treated for bacterial cystitis. Before discharge, it is most important for the client to:

Achieve relief of symptoms and to maintain kidney function

A client who had extensive pelvic surgery 24 hours ago becomes cyanotic, is gasping for breath, and complains of right-sided chest pain. What should the nurse do first?

Administer oxygen using a face mask

A 78-year-old client who had a right above the knee amputation (AKA) 2 days ago is complaining of crushing pain in the right foot. How should the nurse respond to this?

Administer prescribed pain medication.

A client had a thyroidectomy. The nurse monitors for thyrotoxic crisis, which is evidenced by:

An increased temperature and pulse rate

Which client care activity may a nurse safely delegate to a nursing assistant?

Assisting a client who is recovering from an abdominal hysterectomy to the bathroom

A client's membranes spontaneously rupture during active labor. The nurse inspects the perineum and determines that the umbilical cord is not visible. What is the next nursing action?

Auscultating the fetal heart rate

A 41-week multigravida is receiving oxytocin (Pitocin) to augment labor. Contractions are firm and occurring every 5 minutes, with a 30- to 40-second duration. The fetal heart rate increases with each contraction and returns to baseline after the contraction. Which action should the nurse implement

D. Increase the rate of the oxytocin (Pitocin) infusion.

A client with hyperthyroidism is to receive potassium iodide solution before a subtotal thyroidectomy is performed. The nurse concludes that this medication is given to:

Decrease the size and vascularity of the thyroid gland

What expected effect of increased serum cortisone levels does a nurse consider when caring for clients with multiple physical and emotional problems?

Decreased pituitary secretion of adrenocorticotropin hormone (ACTH)

A client who is feeling increasingly tired seeks medical care. Type 1 diabetes is diagnosed. The nurse explains that the increased fatigue is the result of:

Decreased production of insulin by the pancreas

The plan of care for a postoperative client who has developed a pulmonary embolus includes monitoring and bed rest. The client asks why all activity is restricted. The nurse's response is based on the principle that bed rest:.

Decreases the potential for further dislodgment of emboli

A client with type 2 diabetes is admitted for elective surgery. The health care provider prescribes regular insulin even though oral antidiabetics were adequate before the client's hospitalization. The nurse concludes that regular insulin is needed because the:

Dosage can be adjusted to changing needs during recovery from surgery.

A nurse is collecting information about a client who has type 1 diabetes and who is being admitted because of diabetic ketoacidotic coma. Which factors can predispose a client to this condition? Select all that apply.

Excessive emotional stress Correct Incorrect 4 Running a fever with the flu

A client suspected of having a hyperactive thyroid is scheduled for protein-bound iodine, T3, and T4 laboratory tests. To ensure accuracy of the test, the nurse asks if the client has:

Had recent x-rays using radiopaque dye

The parents of a young man suspected of having Cushing syndrome expresses anxiety about their son's condition. What should the nurse tell the parents to help them better understand the illness?

He may have mood swings or depression as a result of his illness.

A nurse, caring for a client with uncontrolled diabetes, suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply.

Headache Correct Incorrect 2 Confusion Profuse sweating

The nurse is caring for a client with type 1 diabetes. For which signs or symptoms of insulin reaction should the nurse particularly be observant? Select all that apply.

Headache Correct Incorrect 3 Diaphoresis

A client who is at 12 weeks' gestation tells a nurse at the prenatal clinic that she is experiencing severe nausea and frequent vomiting. The nurse suspects that the client has hyperemesis gravidarum. What factor is frequently associated with this disorder?

High level of chorionic gonadotropin

Steroid therapy is prescribed for a client with an exacerbation of ulcerative colitis. The nurse evaluates that teaching is effective when the client says, "I should take this medicine:

In the early morning with food."

A client with Parkinson disease complains about a problem with elimination. The nurse should encourage the client to:

Increase residue in the diet

A nurse is caring for several clients with type 1 diabetes, and they each have a prescription for a specific type of insulin. Which insulin does the nurse conclude has the fastest onset of action?

Insulin lispro (Humalog)

The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which of the following?.

Intravenous administration of regular insulin

A nurse is assessing a client experiencing a diabetic coma. What unique response associated with diabetic coma that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client?

Kussmaul respirations

A client who had a brain attack (cerebral vascular accident) several months ago is readmitted to the hospital for a complication of immobility. The nurse reviews the client's laboratory test results, obtains vital signs, and performs a physical assessment. Data reveal elevated white blood cells (WBCs), fever of 101.2, and crackles upon auscultation of the bases bilaterally. Based on the results of the client's work-up, which prescribed medication should the nurse consider the priority at this time?

Levofloxacin (Levaquin

A client is admitted to the hospital with a diagnosis of Cushing syndrome. When performing an assessment, the nurse should take into consideration that the client will most likely exhibit signs of:

Muscle weakness and frequent urination

A client with a primary brain tumor has developed syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The nurse will expect to see which clinical findings upon assessment? Select all that apply.

Nausea and vomiting Increased weight Correct Incorrect 5 Decreased serum sodium Correct Incorrect 6 Decreased level of consciousness

A client at 42 weeks' gestation has a reactive nonstress test. The nurse determines that the client understands what she was taught about the results when she is overheard telling her husband that the test was:

Normal because of an increase in fetal heart rate (FHR) with fetal movement

A nurse is caring for a client with a diagnosis of Cushing syndrome. Which clinical manifestations does the nurse expect to identify? Select all that apply.

Obese trunk Sleep disturbance Thin arms and legs

The health care provider prescribes propylthiouracil (PTU) for a client with the diagnosis of Graves' disease. What should the nurse teach the client when discussing the self-administration of this medication?

Observe for signs of infection

A client who had a subtotal thyroidectomy returns to the unit from the postanesthesia care unit. What is the priority nursing action at this time?

Observe for signs of tetany.

The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis?

PCO2 28, HCO3 18, pH 7.28

A nurse is assessing a client with a diagnosis of hypoglycemia. What clinical manifestations support this diagnosis? Select all that apply.

Palpitations Correct Incorrect 3 Diaphoresis Correct Incorrect 4 Slurred speech

During a routine examination, an enlarged thyroid gland is discovered in a client, and hyperthyroidism is suspected. What clinical findings should the nurse expect to identify when completing a nursing admission history and physical for this client? Select all that apply.

Palpitations Tachycardia Menstrual disturbances

A nurse is caring for a postoperative client who has diabetes. Which is the most common cause of diabetic ketoacidosis that the nurse needs to consider when caring for this client?

Presence of infection

A client with a diagnosis of Graves disease refuses to have radioactive iodine (RAI) therapy, and a subtotal thyroidectomy is performed. What should the nurse do postoperatively to reduce the risk of thyroid storm?

Prevent infection at the surgical site.

The nurse provides care to the client with syndrome of inappropriate antidiuretic hormone (SIADH) by: Select all that apply.

Providing frequent oral care Instituting fall risk precautions Monitoring for and reporting neurologic changes

When a nurse plans to teach a client with type 1 diabetes about the use of an insulin pump, it is of major importance that the client understand that the:

Pump is an attempt to mimic the way a healthy pancreas works

The nurse is assessing a client who is admitted to the hospital with a tentative diagnosis of an adrenal cortex tumor. When assessing the client, which of these, if found, are signs of Cushing disease? Select all that apply.

Round face Correct Incorrect 2 Dependent edema in the feet and ankles Thin, translucent skin with bruising Correct Incorrect 5 Increased fatty deposition in the neck and back

A client with a 40-year history of drinking two alcoholic beverages and smoking two packs of cigarettes daily comes to the outpatient clinic with an ischemic left foot. It is determined that the cause is arterial insufficiency. The nurse concludes that the pain in the client's foot is a result of inadequate blood supply, which may be diminished further by:

Smoking cigarettes

A nurse is caring for a client after a thyroidectomy. Because of concerns about potential nerve injury associated with this type of surgery, the nurse should assess for which functional ability?

Speaking

A client understands that an increase in vitamin E and beta-carotene is important for healthier skin. The nurse teaches the client that excellent food sources of both of these substances are:

Spinach and mangoes

An obese client must self-administer insulin at home. The nurse should teach the client to use what technique?

Spread the tissue and inject at a 90-degree angle

The parents of an 18-month-old toddler are anxious to know why their child has experienced several episodes of acute otitis media. What should the nurse explain to the parents about why toddlers are prone to middle ear infections?

Structural differences between eustachian tubes of younger and older children

A client with hyperthyroidism is treated initially with propylthiouracil (PTU). What should the nurse include when teaching the client about this medication?

Symptoms may not subside until the client has taken the medication for several weeks.

A client is scheduled for a computed tomography (CT) of the brain with contrast. Upon review of the client's medical record, what significant finding should the nurse report to the health care provider before the diagnostic procedure? The client:

Takes metformin (Glucophage) daily.

A 6-year-old child with a leg fracture of suspicious origin is brought into the emergency department by the mother and the mother's boyfriend. It is the child's first visit to this hospital. After assessing the child, a nurse anticipates that the health care provider will order a skeletal survey. Why is a skeletal survey the preferred diagnostic tool?

The skeletal history of the current fracture and any previous healing or healed fractures are identified.

A client is worried about what to expect after having a pancreatoduodenectomy (Whipple procedure) for cancer of the pancreas. What is most important for the nurse to know when helping this client plan for the future?

The stage and grade of the client's cancer

A client has been taking levothyroxine (Synthroid) for hypothyroidism for three weeks. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply.

Tremors Heat intolerance

After a head injury a client develops a deficiency of antidiuretic hormone (ADH). What should the nurse consider about the response to secretion of ADH before assessing this client?

Tubular reabsorption of water increases