Nursing test 5
Which statement made by a client about thyroid hormone replacement therapy (HRT) indicates to the nurse that further teaching is needed? A: "If I continue to lose weight, I may need an increased dose." B: "I will have more energy with this medication." C: "If I often am constipated and feel tired, I may need an increased dose." D: "I will take the medication every morning."
A The statement, "If I continue to lose weight, I may need an increased dose," indicates a need for further teaching. Weight loss indicates a need for a decreased dose, not an increased dose. One of the symptoms of hypothyroidism is lack of energy. Thyroid replacement therapy would cause the client to have more energy. The correct time to take thyroid replacement therapy is in the morning. Frequent constipation and continuing to feel tired are indications that the dose may need to be increased.
Which assessment data would the nurse anticipate in a client with acute pyelonephritis? SATA A: Urinary frequency B: Dysuria C: Oliguria D: Heart rate 120 bpm E: Uremia F: Costovertebral angle tenderness
A, B, D, F
When obtaining a health history of and physical assessment from a 28* year old male client who has a history of enlarged prostate, which finding will the nurse conisder significant?SATA A: Distended bladder B: Absence of bruit C: Frequency of urination D: Dribbling urine after voiding E: Chemical exposure in the workplace
A, C, D
Which assessment has the highest priority for the nurse to perform for a client with syndrome of inappropriate antidiuretic hormone receiving tolvaptan therapy for 24 hours? A: Evaluating serum sodium levels B: Evaluating serum potassium levels C: Evaluating the skin and sclera for jaundice D: Examining the IV site for indications of phlebitis
A, evaluate sodium levels
Which signs and symptoms in a client who has hyperthyroidism indicate to the nurse possible progression to a thyroid storm? (Select all that apply.) Select all that apply. A: Elevated temperature B: Tachycardia C: Somnolence D: Elevated systolic blood pressure E: Abdominal pain and nausea F: Slow respiratory rate
A,B,D,E Symptoms of thyroid storm are caused by excessive thyroid hormone release, which dramatically increases metabolic rate. Key symptoms include fever, tachycardia, and systolic hypertension. Additional symptoms include abdominal pain, nausea, vomiting, diarrhea, tremors, and anxiety. The increased metabolic rate causes the respiratory rate to increase. Clients are agitated, not somnolent.
What assessment data would the nurse anticipate in a client with acute pyelonephritis? A: Urinary frequency B: Dysuria C: Oliguria D: Heart rate 120 beats/min E: Uremia F: Costovertebral angle tenderness
A,B,D,F
A 30 year old male client having an annual health physical reports that all the following changes have developed during the past year. Which ones alert the nurse to possible pituitary hyperfunction? SATAA. A; 15lb weight gain B. Decreased libido C. Four sinus infections D. Frequent constipation E. Increased foot callus formation F. Occasional dripping of clear fluid from both breasts G. Severely sprained ankle from a volleyball injury
A,B,F
A 30- year old male client having an annual health physical reports that all of the following changes have developed during the past year. Which ones alert the following changes have developed during the past year. Which ones alert the nurse to possible pituitary hyperfunction? A: 15 lb weight gain B: Decreased libido C: Four sinus infections D: Frequent constipation E: Increased foot callus formation F: Occasional dripping of clear fluid from both breasts G: Severely sprained ankle from a volleyball injury
A,B,F
Which action immediately after a hypophysectomy will the nurse instruct a client to avoid to prevent harm? (Select all that apply.) Select all that apply. A: Bending at the waist B: Talking C: Deep breathing D: Coughing E: Wearing makeup F: Using dental floss
A,D Coughing early after surgery both increases intracranial pressure (ICP) and also increases pressure in the incision area and may lead to a leak of cerebrospinal fluid. Bending at the waist also increases ICP .The actions of talking and wearing makeup have no harmful effects. In place of coughing, clients are instructed to take deep breaths to promote gas exchange. To prevent harm, clients are taught to avoid toothbrushing (which could injure the incision line) and are encouraged to floss instead.
Which adverse effects will the nurse assess for in a hospitalized client who is prescribed an anticholinergic drug to manage incontinence? SATA A: Insomnia B: Blurred vision C: Constipation D: Dry mouth E: Loss of sphincter control F: Increased sweating G: Worsening mental function
B, C, D, G
A client newly diagnosed with type 1 diabetes says she is not ready to learn everything about diabetes control right now. Which information has the greatest priority for the nurse to teach this client and her family for now to prevent harm? (Select all that apply.) Select all that apply. A: Causes of type 1 diabetes B: What to do when ill? C: Symptoms and treatment of hypoglycemia D: Insulin administration E: Dietary control of blood glucose F: Importance of regular exercise
B,C,D The priority information for safety and preventing harm that the nurse needs to teach the client and family about diabetes are: Symptoms and management of hypoglycemia because it is a life-threatening condition. Proper insulin administration is essential for the management of type 1 diabetes and to prevent death. Knowing what to do when ill is critical information because illness will require changes in the client's day-to-day use of insulin and may need contact with the client's diabetes health care provider to prevent harm. The causes of diabetes, dietary control, and exercise are less important for immediate safety and can be taught at another time.
The nurse is admitting a client undergoing a CT scan with contrast. Which finding does the nurse report as a possible immediate hypersensitivity reaction? SATA A: Nausea B: Pruritus' C: Urticaria D: Laryngeal stridor E: Flushing of the skin
B,C,D,E
Which hormones help prevent hypoglycemia? A: Aldosterone B: Cortisol C: Epinephrine D: Growth hormone E: Glucagon F: Insulin G: Norepinephrine H: Proinsulin
B,C,D,E,G
Which of the following are associated with diabetes insipidus? SATA A. urine output of 2000 mL/hr B. urine output of 4300 mL/hr C. urine specific gravity < 1.005 D. bradycardia E. increased thirst
B,C,E
The nurse is teaching a class about kidney and urinary changes that occur with age. What teaching will the nurse include? (Select all that apply.) Select all that apply. A: Drug clearance is often increased which produces more drug reactions. B: Glomerular filtration rate decreases which increases the risk for fluid overload. C: Urinary sphincters lose tone and weaken with age. D: Blood flow to the kidneys increases promoting nocturia. E: The ability to concentrate urine decreases which creates urgency.
B,C,E Blood flow to the kidneys decreases (not increases) with age. Nocturnal polyuria is associated with tubular changes that cause a decrease in the concentration of urine. Drug clearance is often decreased which is what leads to more drug reactions.
Which precaution is most important for the nurse to teach a female client to prevent harm while undergoing drug therapy with estrogen and progesterone for hypopituitarism? A: Use a barrier method of contraception to prevent unplanned pregnancy's B: Wear a hat with a brim and sunscreen when out doors C: Do not smoke or use nicotine in any form D: Avoid drinking caffeinated beverages
C
A client is taking Bromocriptine mesylate. Which statement from the client requires further teaching? A. "I'll take this medication in the morning" B. "I'll take this medication before bed" C. "I'll take this medication on an empty stomach" D."I'll lay down immediatley after taking this medication"
C
The nurse is providing discharge teaching to a client who is recovering from kidney transplantation. Which client statement indicates understanding? A: I can stop my medications when my kidney function returns to normal B: If my urine output decreases, I will increase my fluids C: The antirejection medications will be taken for life D: I will drink 8 ounces of water with my medications
C
What medication would you use for a patient with SIADH that has a sodium level of 114? A Baclofen B Oxybutynin C Tolvaptan D Furosemide
C
Which statement regarding trophic hormones are true? A: all are categorized as catecholamines B: Responses are independent of target tissue receptors C: Their target tissues are always another endocrine gland D: They represent the final hormone secreted in a complex negative feedback pathway
C
Which items are most important for the nurse to ensure are in the room when a client returns from having a thyroidectomy? (Select all that apply.) Select all that apply. A: Hypertonic saline B: Furosemide C: Calcium gluconate D: Oxygen E: Suction F: Emergency tracheotomy kit
C,D,E,F Calcium gluconate needs to be available at the bedside to treat hypocalcemia and tetany that might occur if the parathyroid glands have been injured during the surgery. Equipment for an emergency tracheotomy must be kept at the bedside in the event that hemorrhage or edema occludes the airway. Oxygen always needs to be at the bedside and especially for the thyroidectomy client who may experience respiratory distress from swelling or damage to the laryngeal nerve leading to spasm. It is also important to have suction available at the client's bedside because of the risk for increased secretions. Furosemide is a diuretic used to treat hypercalcemia associated with hyperparathyroidism. However, hypocalcemia from inadvertent parathyroid removal during thyroidectomy is the greater concern. Hypertonic saline is not necessary for this client. This client is not expected to have hyponatremia after
Which assessment data in a client with chronic glomerulonephritis (GN) warrants the nurse to contact the primary health care provider? A: Itchy skin B: Serum potassium of 5.0 mEq/L (5.0 mmol/L) C: Mild proteinuria D: Third heart sound (S3)
D When a third heart sound (S3) is heard in a client with chronic glomerulonephritis, the nurse needs to contact the primary health care provider. S3 indicates fluid overload secondary to failing kidneys. The primary health care provider would be notified and instructions obtained. Mild proteinuria is an expected finding in GN. A serum potassium of 5.0 mEq/L (5.0 mmol/L) reflects a normal value. Intervention would be needed for hyperkalemia. Although itchy skin may be present as kidney function declines, it is not a priority over fluid excess.
The nurse is preparing a client with stage 3 CKD for discharge. Which client statement indicates the need for further teaching? A: I will be sure to attend my follow up appointment with my nephrologist B: I will increase my protein intake so my body can heal C: I will weigh myself daily and call the doctor if my weight increases by 2lb or more D: I will take my blood pressure each day and keep a daily log
B
The nurse is reviewing the clients laboratory data prior to a nephrostomy tube insertion. Which data requires the nurse to take action? A: White blood cells in the urine B: INR of 2.1 C: Hematocrit of 44% D: Creatinine of .8
B
When assessing a client with acute glomerulonephritis which question will the nurse ask to determine if the client is following best practices to slow progression of kidney damage? A: Do you avoid contact sports while you are taking cyclosporine B: How are you evaluating the amount of daily fluid you drink? C: Have you contacted anyone from our dialysis support services D: Have you increased your protein intake to promote healing of the damaged nephrons?
B
Which assessment finding in a 40-year old client is most relevant for the nurse to assess further for a possible endocrine problem? A: He has lost 10 lb in the past month following a low-carbohydrate eating plan B: The client reports now needing to shave only once weekly instead of daily C: His new prescription for eyeglasses is for a higher strength D: The clients father died of a stoke at age 70 years.
B
Which electrolyte laboratory values indicate to the nurse monitoring a client with adrenal insufficiency undergoing IV therapy with hydrocortisone that the client is responding positively to this drug therapy? A: Serum sodium 147, serum potassium 7.1 B: Serum sodium 137, serum potassium 4.9 C: Serum sodium 127, serum potassium 2.8 D: Serum sodium 119, serum potassium 6.2
B
Which question will the nurse ask the client who has a urinary tract infection to assess the risk of pyelonephritis? A: What drugs do you take for asthma B: How long have you had diabetes C: How much fluid do you drink per day D: Do you take your antihypertensive drugs at night or in the morning?
B
Which specific action is a priority for the nurse to teach a client with diabetes who has peripheral neuropathy to prevent harm? A: "Wear a medical alert bracelet." B: "Never go barefoot." C: "Never reuse insulin syringes." D: "Drink at least 3 L of fluids daily."
B All the actions are important for the client with diabetes to perform for safety and to prevent a variety of complications. However, the most important action to prevent harm from peripheral neuropathy is to never go barefoot and wear shoes and slippers with firm soles.
For which client will the nurse question the prescription for long-term androgen therapy? A: A 40 year old who also has syndrome of inappropriate antidiuretic hormone (SIADH). B: A 52 year old with a history of prostate cancer treatment. C: A 30 year old who is taking antiviral therapy for HIV disease. D: A 66 year old with impotence that is resistant to standard erectile dysfunction therapy.
B Androgen therapy can make any residual prostate cancer cells proliferate and cause a recurrence of the disease. This therapy is often prescribed for impotence. SIADH is not a contraindication for the therapy and neither is HIV disease or its treatment.
Which precaution is most important for the nurse to teach a client who has cardiovascular autonomic neuropathy (CAN) from diabetes to prevent harm? A: "Check your hands and feet weekly for chronic excessive sweating." B: "Change positions slowly when moving from sitting to standing." C: "Avoid drinking caffeine or caffeinated beverages." D: "Be sure to take your blood pressure drug daily."
B Cardiovascular autonomic neuropathy (CAN) affects sympathetic and parasympathetic nerves of the heart and blood vessels. This problem contributes to left ventricular dysfunction, painless myocardial infarction, and exercise intolerance. Most often, CAN leads to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing). These problems are from failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. As a result, blood flow to the brain is interrupted briefly. Orthostatic hypotension and syncope increase the risk for falls, especially among older adults.Although taking blood pressure medication daily is important, it does not prevent orthostatic hypotension and in fact, may make orthostatic hypotension worse. Sensation changes are associated with peripheral neuropathy, not cardiovascular autonomic neuropathy. Avoiding caffeine is no longer a recommended action.
What is the nurse's best response when a client with Cushing syndrome screams at her husband, bursts into tears, throws her water pitcher against the wall, and then says "I feel like I am going crazy"? A: "You must learn to control your behavior. Because you are disturbing others, I am going to keep the door to your room closed and restrict your visitors." B: "You feel this way because of your high hormone levels. Your health care provider can prescribe an antianxiety drug for you." C: "I will tell your primary health care provider order a psychiatric consult for you." D: "You are probably feeling this way because you are frightened about having a chronic disease. Would you like some information about a support group?"
B Changes in blood cortisol levels can cause the client to show neurotic or psychotic behaviors. The client's need to know that these behavior changes do not reflect a true psychiatric disorder and will resolve when therapy results in lower and more steady blood cortisol levels. Drug therapy to reduce these feelings and behaviors may be appropriate. A psychiatric consult is not likely to be needed. A support group may be indicated depending on why the client has hypercortisolism but the nurse should not make assumptions about the client's feelings and possible fears. Punishing the client for her behavior does not solve the problem or help the client understand her feelings.
What is the nurse's best response when a client, who has been taking high-dose corticosteroid therapy for a month for a problem that has now resolved, asks you why she needs to continue taking the corticosteroid? A: "Corticosteroids are a type of hormone, and once you have been started on a replacement hormone, you must continue the hormone replacement therapy for the rest of your life." B: "The drug suppressed your own adrenal gland secretion of corticosteroids. Slowly decreasing the dose over time allows your adrenal glands to start adequate secretion again." C: "It is possible for your health problem to recur when corticosteroid therapy is halted suddenly." D: "The drug suppressed your immune system while you were taking it. Slowly decreasing the dose over time prevents your immune system from starting up too quickly and causing allergic reactions."
B Changes in blood cortisol levels can cause the client to show neurotic or psychotic behaviors. The client's need to know that these behavior changes do not reflect a true psychiatric disorder and will resolve when therapy results in lower and more steady blood cortisol levels. Drug therapy to reduce these feelings and behaviors may be appropriate.A psychiatric consult is not likely to be needed. A support group may be indicated depending on why the client has hypercortisolism but the nurse should not make assumptions about the client's feelings and possible fears. Punishing the client for her behavior does not solve the problem or help the client understand her feelings.
Which statement made by the client alerts the nurse to the possibility of hypothyroidism? A: "I seem to feel the heat more than other people." B: "I am always tired, even when I get 10 or 12 hours of sleep." C: "Food just doesn't taste good without a lot of salt." D: "My grandmother had thyroid problems."
B Clients with hypothyroidism usually feel tired or weak and often report an increase in time spent sleeping, sometimes up to 14 to 16 hours per day. Thyroid problems are very common among women and do not demonstrate a specific pattern of inheritance. Clients with hypothyroidism have a slow metabolism and have difficulty keeping warm. Salt craving is not a symptom of hypothyroidism.
Clients who have deficiencies of which hormones will the nurse assess for increased risk of life-threatening consequences? A: Prolactin and prolactin inhibiting hormone (PIH) B: Adrenocorticotrophicn hormone (ACTH) and thyroid-stimulating hormone (TSH) C: Growth hormone (GH) and melanocyte-stimulating hormone (MSH) D: Follicle-stimulating hormone (FSH) and luteinizing hormone (LH)
B Deficiencies of (ACTH) or TSH are the most life threatening because they cause a decrease in the secretion of vital hormones from the adrenal and thyroid glands. Deficiencies of the other hormones result in significant changes but these deficiencies are not incompatible with life.
The client diagnosed with Addison's disease asks the nurse, "Why do I have to take fludrocortisone?" Which statement is the nurse's best response? 1. "It will keep you from getting high blood sugars." 2. "Fludrocortisone helps the body retain sodium." 3. "Fludrocortisone prevents muscle cramping." 4. "It stimulates the pituitary gland to secrete adrenocorticotropic hormone
2
Performance of which assessment is priority for the nurse before giving a client the first oral dose of hormone replacement therapy for hypothyroidism? A: Measuring heart rate and rhythm B: Checking core body temperature C: Asking about previous allergic drug reactions D: Listening to bowel sounds in all four abdominal quadrants
A
What gland secreates the growth hormone (GH)? A. anterior pituitary B. thyroid C. andrenal corex D. testes
A
Which assessment finding of a client 8 hours after a subtotal thyroidectomy does the nurse consider most relevant as an indication of possible complications? A: The clients hand spasms during blood pressure assessment B: The respiratory rate has dropped from 18 to 14 breaths per min C: The dressing has moderate amount of serosanguineous drainage D: The client responds to questions correctly but does not open the eyes while talking
A
How will the nurse reply when a client with type 2 diabetes tells the nurse that he would like to have a 12-ounce glass of beer with supper but believes that is now impossible? A: "You can have a beer with a meal if you test yourself for hypoglycemia an hour later." B: "You can have a beer with a meal if you test yourself for hyperglycemia an hour later." C: "There are nonalcoholic beers available that you can substitute for a regular beer." D: "If you gave up dessert, you can still have one beer."
A Alcohol consumption contributes to hypoglycemia. This risk is reduced if the alcohol is consumed with or shortly after a meal. The client is instructed to check blood glucose levels about an hour after alcohol is consumed to determine if either more food is needed or if insulin dosage needs to be adjusted.
When performing bladder scanning to detect residual urine in a female client, the nurse must first assess which factor? A: History of hysterectomy B: Abdominal girth C: Hematuria D: Presence of urinary infection
A Before performing bladder scanning to detect residual urine in a female client, the nurse must first determine if the client has had a hysterectomy. The scanner must be in the scan mode for female clients in order to ensure the scanner subtracts the volume of the uterus from the measurement. If the client has had a hysterectomy, the scanner should remain in the scan mode for males.The nurse performs this procedure in response to distention or pressure in the bladder; girth is not a factor. This procedure detects urine retained in the bladder, not infection. The presence of retained urine in the bladder is assessed, regardless of hematuria.
For which change reported by a client taking bromocriptine therapy to manage hyperpituitarism will the nurse notify the primary health care provider immediately to prevent harm? A: Chest pain B: Constipation C: Headache D: Increased sleepiness
A Bromocriptine can cause serious cardiac dysrhythmias and coronary artery spasms. Constipation, increased sleepiness, and headaches are possible side effects of the drug and their degree of discomfort to the client always should be considered; however, their presence does not constitute harm or require immediate attention.
Which statement made by a client who is learning about self-injection of insulin indicates to the nurse that clarification is needed about injection site selection and rotation? A: "The abdominal site is best because it is closest to the pancreas." B: "I can reach my thigh best, so I will use different areas of the same thigh." C: "If I change my injection site from the thigh to an arm, the inulin absorption may be different." D: "By rotating sites within one area, my chance of having skin changes is less."
A The abdominal site has the fastest and most consistent rate of absorption because of the blood vessels in the area and not because of its proximity to the pancreas. The other statements demonstrate correct understanding about injection site selection and rotation.
The nurse has just received report on a group of clients. Which client is the nurse's first priority? A: A 26 year old with type 1 diabetes whose insulin pump is beeping "occlusion." B: A 30 year old with type 1 diabetes who is reporting thirst. C: A 40 year old with type 2 diabetes who has a blood glucose of 150 mg/dL (8.3 mmol/L). D: A 50 year old with type 2 diabetes with a blood pressure of 150/90 mm Hg.
A The client the nurse sees first is the client with type 1 diabetes whose insulin pump is beeping "occlusion." Because glucose levels will increase quickly in clients whose continuous insulin pumps malfunction, the nurse must assess this client and the insulin pump first to avoid hyperglycemia or diabetic ketoacidosis. Thirst is an expected symptom of hyperglycemia and, although important, is not a priority. The nurse could delegate fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL (8.3 mmol/L) is mildly elevated, this does not require immediate action. Mild hypertension does not require immediate action. The nurse can later assess if this is within the client's usual range or represents a change before taking action.
Which primary health care provider order will the nurse perform first for a client with syndrome of inappropriate antidiuretic hormone (SIADH) who has a serum sodium level of 105 mEq/L (105 mmol/L)? A: Administering an infusion of 150 mL hypertonic saline over the next 3 hours B:: Drawing blood for hemoglobin and hematocrit levels C: Measuring serial weights at the same daily with the client wearing the same amount of clothing D: Inserting an indwelling catheter and monitoring urine output
A The first intervention the nurse performs is to administer an infusion of 150 mL hypertonic saline over 3 hours. When the serum sodium level is below 115 mEq/L (115 mmol/L), the client is at increased risk for seizures and coma. Drawing blood for hematocrit and hemoglobin levels, inserting an indwelling catheter for urine monitoring, and weighing the admitted client are not top priority actions.
What is the nurse's best action when noticing that the phlebotomist, who plans to draw blood from the client with severe hypercortisolism, displays symptoms of a cold? A: Ensuring the phlebotomist wears a facemask while in the client's room B: Asking the phlebotomist to delay the blood draw C: Monitoring the client closely for cold-like symptoms D: Placing a facemask on the client
A The nurse needs to make sure the phlebotomist wears a facemask because the client is immunosuppressed and at higher risk for respiratory infection. Anyone with a suspected upper respiratory infection who must enter the client's room needs to wear a mask to prevent the spread of infection. Asking the phlebotomist to delay the blood draw could lead to harm by not providing sufficient information about the client's condition. The phlebotomist, not the client, is exhibiting cold-like symptoms, so monitoring the client for these symptoms is not appropriate. Having the client wear a mask during the blood draw does not protect him or her from any airborne microorganisms that remain in the atmosphere of the room or droplets that may reside on surfaces.
A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared that I can't do it all and will get so sick that I will be a burden on my family." What is the nurse's best response? A: "Let's tackle it piece by piece. What is most scary to you?" B: "It is overwhelming, isn't it?" C: "Let's see how much you can learn today, so you are less nervous." D: "Many people live with diabetes and do it just fine."
A The nurse's best response is to suggest that the client tackle it piece by piece and ask what is most scary to him or her. This is the best client-centered response, and acknowledges the client's concern, letting the client master survival skills first. Referring to the illness as overwhelming may reflect the client's feelings, but is a closed-ended question and does not encourage the client to express his feelings about the underlying fear. Trying to see how much the client can learn in 1 day may add to his anxiety by overwhelming him with information and the need to "do it all" in 1 day. Suggesting that other people handle the illness just fine criticizes the client and does not recognize his concerns.
Which change in serum electrolyte values in the past 12 hours for a client with syndrome of inappropriate antidiuretic hormone (SIADH) being treated with tolvaptan will the nurse report immediately to the health care provider? A: Serum sodium increases from 122 mEq/L to 140 mEq/L. B: Serum potassium decreases from 4.2 mEq/L to 3.8 mEq/L. C: Serum chloride decreases from 109 mEq/L to 99 mEq/L. D: Serum calcium increases from 9.5 mg/dL to 10.2 mg/dL.
A The purpose of tolvaptan is to restore a normal sodium concentration to the blood and other extracellular fluid. In the case of syndrome of inappropriate antidiuretic hormone, excessive amounts of antidiuretic hormone have caused more water to be absorbed, causing the serum sodium to be diluted. When tolvaptan therapy brings the serum sodium level to normal levels, it must be discontinued to prevent hypernatremia. A serum sodium of 140 mEq/L is within the normal range.
The nurse is caring for a client with uremia. What assessment data will the nurse anticipate? A: Nausea and vomiting B: Insomnia C: Cyanosis of the skin D: Tenderness at the costovertebral angle (CVA)
A The signs and symptoms the nurse needs to assess for are nausea and vomiting. Other manifestations of uremia include anorexia, nausea, vomiting, muscle cramps, pruritus, fatigue, and lethargy. CVA tenderness is a sign of inflammation or infection in the renal pelvis. Cyanosis is related to poor tissue perfusion. Insomnia is nonspecific and may be caused by psychoemotional factors, medications, or other problems.
The nurse recognizes which of the following symptoms can be seen in benign prostatic hypertrophy? SATA A: Urinary frequency B: Urinary Urgency C: Fever and chills D: Low back pain E: Dilute urine D: Knife-like back pain
A,B,D
For which symptoms will the nurse instruct the family and client who is being treated for diabetes insipidus (DI) to call 911 or go to the nearest emergency department? (Select all that apply.) Select all that apply. A: Decreased urine output B: Hypotension C: Weigh gain of more than 2.2 lb (1 kg) in 24 hours D: Persistent headache E: Hyperglycemia F: Acute confusion
A,C,D,E Drug therapy for DI can cause a greatly increased kidney reabsorption of water and lead to life-threatening water toxicity. Indications of water toxicity are a relatively rapid onset of acute confusion, rapid weight gain, decreased urine output, persistent headache, and nausea and vomiting. Clients become hypertensive (not hypotensive). Usually blood glucose levels are unaffected but can be diluted below normal levels.
What is the nurse's best response when a client with diabetes who is being treated for hypoglycemic asks why people without diabetes don't become severely hypoglycemic even after fasting for 8 hours? A: In a person without diabetes, fasting for 8 hours converts proteins into glycose (gluconeogenesis) so that hypergycemia develops rather than hypoglycemia. B: In a person without diabetes, the secretion of glucagon prevents hypoglycemia by promoting glucose release from liver storage sites (glycogenolysis). C: Normal metabolism is so slow when a person without diabetes fasts that blood glucose does not enter cells to be used for energy. As a result, hypoglycemia does not occur. D: Lipolysis (fat breakdown) in fat stores occurs faster in the nondiabetic person, which converts fatty acids into glucose to maintain blood glucose levels.
B Glucagon is a counter-regulatory hormone secreted by pancreatic alpha cells when blood glucose levels are low, as they would be during an 8 hour fast. The body's metabolic rate does decrease during sleep (which is not stated in this question) but not sufficiently to prevent hypoglycemia. Glucagon works on the glycogen stored in the liver, breaking it down to glucose (glycogenolysis) molecules that are then released into the blood to maintain blood glucose levels and prevent hypoglycemia. Although proteins can be broken down and converted to glucose, they are not converted to glycogen. Fat break down through lipolysis can provide fatty acids for fuel but this is not glucose and lipolysis does not occur until all stored glycogen is used.
Why is a goiter often present in clients who have Graves disease? A: The low circulating levels of thyroid hormones stimulates the feedback system and triggers the anterior pituitary gland to secrete more thyroid-stimulating hormone, which increases the numbers and size of glandular cells in the thyroid gland. B: The excessive autoantibodies bind to the thyroid-stimulating hormone receptor sites, which increases the number and size of glandular cells in the thyroid gland. C: The autoantibodies stimulate blood vessel growth and blood storage within the thyroid gland, increasing its overall size. D: The autoantibodies stimulate the inflammatory and immune responses to increase the number of white blood cells circulating in the thyroid gland, which increases tissue size without increasing the number of glandular cells.
B Graves disease is an autoimmune disorder in which antibodies (thyroid-stimulating immunoglobulins [TSIs]) are made and attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid tissue. The thyroid gland responds by increasing the number and size of glandular cells, which enlarges the gland, forming a goiter and overproduces thyroid hormones (thyrotoxicosis).
In collaboration with the registered dietitian nutritionist, which dietary alterations will the nurse instruct a client with Cushing disease to make? A: High carbohydrate, low potassium, and fluid restriction B: Low carbohydrate, high calorie, and low sodium C: Low protein, high carbohydrate, and low calcium D: High protein, high carbohydrate, and low potassium
B The client with Cushing disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of total calories and carbohydrates to prevent or reduce the degree of hyperglycemia. The sodium retention causes water retention and hypertension. Clients are encouraged to moderately restrict sodium intake.
When assessing a client with acute glomerulonephritis, which assessment finding causes the nurse to notify the primary health care provider? A: Purulent wound on the leg B: Crackles throughout the lung fields C: Cola-colored urine D: History of diabetes
B The nurse notifies the primary health care provider if crackles throughout the lung fields are heard in a client with acute glomerulonephritis. Crackles indicate fluid overload resulting from kidney damage. Shortness of breath and dyspnea are typically associated. The primary health care provider must be notified of this finding. Glomerulonephritis may result from infection (e.g., purulent wound); it is not an emergency about which to notify the primary health care provider. The history of diabetes would have been obtained on admission. Dark urine is expected in glomerulonephritis.
During discharge teaching for a client with kidney disease, what does the nurse teach the client to do? A: "Eat breakfast and go to bed at the same time every day." B: "Drink 2 L of fluid and urinate at the same time every day." C: "Weigh yourself and take your blood pressure." D: "Check your blood sugar and do a urine dipstick test."
B When discharging the client with kidney disease, the nurse needs to tell the client to "Weigh yourself and take your blood pressure." Regular weight assessment monitors fluid restriction control while blood pressure control is necessary to reduce cardiovascular complications and slow the progression of kidney dysfunction. Fluid intake and urination, and breakfast time and bedtime, do not need to be at the same time each day. The Clients with diabetes, not kidney disease, would regularly check their blood sugar and perform a urine dipstick test.
What is the nurse's best action when finding that a client who has had diabetes for 15 years has decreased sensory perception in both feet? A: Testing the sensory perception of the client's hands B: Examining both feet for indications of injury C: Explaining to the client that peripheral neuropathy is now present D: Documenting the finding as the only action
B When reduced peripheral sensory perception is present, the likelihood of injury is high. Any open area or other problem on the foot of a person with diabetes is at great risk for infection and must be managed carefully and quickly. Checking for sensory perception on the hands and other areas is important but can come after a thorough foot examination.
Which assessment findings in a client with hyperthyroidism indicate to the nurse that the client is in danger of thyroid storm? SATA A:increased salivation B: Client reports increased of palmar sweating C: Decreased pulse pressure from 40 - 36 D: Diminished bowel sounds in all four abdominal quadrants E: An increase in temperature from 99.5 to 101.3 F: Serum sodium level increase from 136-139 G: Increase in premature ventricular contractions from 4 per minute to 28 per minute
B, E, G
A patient recently started taking levothyroxine (synthroid) for a new diagnosis of hypothyroidism. What should the nurse include in the patient's teaching? Select all that apply. A. take this medication with a full glass of milk B. take this medication 30 minutes to 1 hour before breakfast C. do not stop taking this medication abruptly D. take this medication at bedtime
B,C
Which statements regarding hyperthyroidism are accurate? (Select all that apply.) Select all that apply. A: Has a sudden onset of symptoms. B: Is much more common among women than among men. C: Produces symptoms of a hypermetabolic state. D: Most common form is Graves disease. E: Can be diagnosed by the presence of a goiter. F: Often occurs weeks after exposure to ionizing radiation.
B,C,D Hyperthyroidism increases the metabolism and function of all systems. The most common cause of hyperthyroidism is Graves disease, which is an autoimmune disorder, often occurring after an episode of thyroid inflammation leading to the production of autoantibodies (thyroid-stimulating immunoglobulins [TSIs]) that attach to the thyroid-stimulating hormone (TSH) receptors on the thyroid gland. The increased stimulation of TSH receptors greatly increases thyroid hormone production. All thyroid problems are from five to ten more common among women than men. The onset is so slow and insidious that clients may not even notice them until severe changes are present. A goiter only indicates a thyroid problem and can occur with both hypothyroidism and hyperthyroidism. Exposure to ionizing radiation can induce hypothyroidism, not hyperthyroidism.
When assessing a client with acute pyelonephritis, which finding does the nurse anticipate? (Select all that apply.) Select all that apply. A:Oliguria B: Vomiting C: Dysuria D: Chills E: Suprapubic pain
B,C,D The findings the nurse expects to find in a client with acute pyelonephritis include: vomiting, chills, and dysuria. Nausea and vomiting and chills along with fever may occur. Dysuria (burning), urgency, and frequency can also occur. Suprapubic pain is indicative of cystitis, not kidney infection (pyelonephritis). Flank, back, or loin pain are symptoms of acute pyelonephritis. Oliguria is related to kidney impairment from severe or long-standing pyelonephritis.
Which lab finding is indicative of renal function alterations but not dehydrations? SATA A: BUN 20 B: Creatinine 2.3 C: hemoglobin 14 D: Cystatin- C 105 E: BUN/Creatinine ratio 10 F: Creatinine clearance 175mL/min
B,D,F
Which signs, symptoms, or behaviors will the nurse expect to find when assessing a client who has just been diagnosed with hypothyroidism? (Select all that apply.) Select all that apply. A: Goiter B: Nonpitting edema of hands and feet C: Warm, moist skin D: Decreased deep tendon reflexes E: Agitation and inability to sleep F: Pulse rate below 60 beats/min
B,D,F Hypothyroidism slows the metabolism and function of all systems and the ones that are usually first noticed and can lead to life-threatening complications are the cardiac and central nervous systems. Thus, the heart rate is usually slower than 60 beats/min, and the deep tendon reflexes are decreased. Metabolites that are compounds of proteins and sugars called glycosaminoglycans (GAGs) build up inside cells, which increase the mucus and water, forming cellular edema that is nonpitting. The onset is so slow and insidious that clients may not even notice them until severe changes are present. A goiter only indicates a thyroid problem and can occur with both hypothyroidism and hyperthyroidism. The skin reflects the client's overall decreased metabolism and is cool and dry.
Which urine characteristics indicate to the nurse that the client being managed for diabetes insipidus is responding appropriately to interventions? A: Urine output volume decreased, urine specific gravity increased B: Urine output volume increased, urine specific gravity decreased C: Urine output volume decreased, urine specific gravity increased D: Urine output volume increased, urine specific gravity decreased
C
Which action will the nurse recommend to a client with type 1 diabetes on insulin therapy who has been having a morning fasting blood glucose (FBG) level of 160 mg/dL (8.9 mmol/L) and is diagnosed with "dawn phenomenon" to achieve better control? A: Eat a bedtime snack containing equal amounts of protein and carbohydrates." B: Avoid eating any carbohydrate with your evening meal." B: Take your evening insulin dose right before going to bed instead of at supper time." C: Inject the insulin into your arm rather than into the abdomen around the navel."
C A client with "dawn phenomenon," diagnosed by checking blood glucose levels during the night, has morning hyperglycemia that results from a nighttime release of adrenal hormones causing blood glucose elevations at about 5 to 6 a.m. It is managed by providing more insulin for the overnight period (e.g., giving the evening dose of intermediate-acting insulin at 10 p.m. instead of with the evening meal).Bedtime snacks are needed for "Somogyi phenomenon" that is morning hyperglycemia caused by the counterregulatory response to nighttime hypoglycemia. Changing the injection site would not prevent morning hyperglycemia. Not eating any carbohydrate with a meal is more likely to cause severe hypoglycemia during the night and is dangerous.
What is the nurse's best response to a client newly diagnosed with type 1 diabetes who asks why insulin is only given by injection and not as an oral drug? A: "Injected insulin works faster than oral drugs to lower blood glucose levels." B: "Oral insulin is so weak that it would require very high dosages to be effective." C: "Insulin is a small protein that is destroyed in by stomach acids and intestinal enzymes." D: "Insulin is a "high alert drug" and could more easily be abused if it were available as an oral agent."
C Because insulin is a small protein that is easily destroyed by stomach acids and intestinal enzymes, it cannot be used as an oral drug. Most commonly, it is injected subcutaneously.
Which client symptom appearing after a head injury suffered in a car crash is most relevant for the nurse to consider the possibility of diabetes insipidus (DI)? A: New-onset hypertension. B: The client reports extreme salt craving. C: No change in urine output with minimal fluid intake. D: The client's headache is gradually increasing in intensity.
C DI results from absent or insufficient secretion of antidiuretic hormone (ADH, vasopressin) from the posterior pituitary and can result from a head injury that damages this endocrine gland. With less or absent ADH, the client is unable to reabsorb water even when fluid intake is low. Although headache is usually present with a head injury, it is not associated with DI. The dehydration associated with DI would cause hypotension and an increased serum sodium concentration.
When (at which time) will the nurse plan to monitor for hypoglycemia in a client with type 1 diabetes received regular insulin at 7:00 a.m.? A: 7:30 a.m. B: 7:30 p.m. C: 11:00 a.m. D: 2:00 p.m.
C Regular insulin is a short-acting type of insulin. Onset of action to regular insulin is ½ to 1 hour. The peak effect time is when hypoglycemia may start to occur. Peak time for regular insulin is 2 to 4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m. The other options for peak times for regular insulin are incorrect.
Which precaution will the nurse include when providing instructions to the female client with hypothyroidism who is prescribed to take thyroid hormone replacement therapy (HRT)? A: "Increase the amount of fiber in your diet to prevent the side effect of constipation." B: "Stop this drug immediately if you discover you are pregnant." C: "Avoid over-the-counter medications unless prescribed by your primary health care provider." D: "If you miss a dose, double your next day's dose."
C The amount of drug in synthetic thyroid hormone tablets is very small and many other foods and drugs interfere with its absorption. The client is instructed to not take over-the-counter medications without approval from the primary health care provider. Fiber greatly interferes with the drug's absorption and is not to be taken with or within 4 hours of HRT. In addition, the drug does not cause constipation. Thyroid HRT must continue during pregnancy. The therapy works best when blood levels are maintained. The client is taught to take the forgotten drug as soon as it is remembered and not to double the next day's dose.
What is the nurse's best response to a client with type 2 diabetes controlled with metformin who asks why now that he is recovering from surgery, is he prescribed to receive insulin therapy for a few days? A: "Your insurance doesn't permit metformin to be used during hospitalization." B: "Your presurgical testing indicates that you now have type 1 diabetes and require daily insulin." C: "You just need insulin temporarily because the stress of surgery causes increased blood glucose levels for a day or two." D: "You must take insulin from now on because the surgery has aggravated the intensity of your diabetes."
C The nurse's best response is that due to the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for clients with diabetes who use oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides. No evidence suggests that the client's diabetes has worsened. However, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital, but not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed.
An assistive personnel reports that a nursing home client who has hypothyroidism has a pulse of 48 bpm this morning. Which assessments have the highest priority for the nurse to perform immediately? SATA A: Checking body temperature B: Testing deep tendon reflexes C: Measuring oxygen saturation by pulse oximetry D: Checking blood pressure, heart rate, and rhythm E: Determining level of consciousness F: Identifying presence or absence of the swallowing reflex G: Examining feet and ankles for indications of peripheral edema
C, D Measuring oxygen saturation, checking blood pressure heart rate , and rhythm
A nurse is caring for a client with Cushing syndrome who must remain on continued glucocorticoid therapy for another health problem will use which of the following actions to prevent harm? A: Urging the client to salt his or her food B: Testing voided urine for the present of glucose C: Using nonadhesive methods to secure IV access D: Ensuring the prescribed glucocorticoid drug is given on an empty stomach
C, using a non adhesive method to secure IV access
Which question is most relevant to ask a male client suspected to have a gonadotropin deficiency? A: "Are you experiencing any pain during sexual intercourse?" B: "Do you work with or have hobbies that involve exposure to chemicals?" C: "Have you gained or lost any weight recently?" D: "How often do you need to shave your face?"
D A gonadotropin deficiency reduces the expression of secondary sexual characteristics and leads to decreased libido and fertility in both male and female clients. Male clients lose facial fair and need to shave less frequently. This change may be the first problem noticed by the client. A deficiency does not result in painful intercourse for men although it can in women from vaginal dryness.
Which action does the postanesthesia care unit (PACU) nurse perform first when caring for a client who has just arrived after a total thyroidectomy? A: Administering morphine for pain B: Assessing the wound dressing for bleeding C: Hyperextending the neck D: Monitoring oxygen saturation
D Airway assessment and management is always the first priority with every client, especially for a client who has had surgery that involves potential bleeding and edema near the trachea. Assessing the wound dressing for bleeding is a high priority, which is performed next after assessing airway and breathing. Pain control is important, but can be addressed after airway assessment. The neck should not be extended or hyperextended because this position puts too much tension on the incision.
Which client does the nurse caution to avoid self-monitoring of blood glucose (SMBG) at alternate sites? A: A 55-year-old client who has hypoglycemic unawareness B: An 80-year-old client with type 2 diabetes mellitus C: A 45-year-old client with type 1 diabetes mellitus D: A 75-year-old client whose blood glucose levels show little variation
D Comparison studies have shown wide variation between fingertip and alternate sites, and variation is most evident during times when blood glucose levels are rapidly changing. Clients are taught that there is a lag time for blood glucose levels between the fingertip and other sites when blood glucose levels are changing rapidly and that the fingertip reading is the only safe choice at those times. Because of this lag time, clients who have hypoglycemic unawareness are warned to not ever use alternate sites for SMBG.
Which changing trends in a client's serum laboratory values indicate to the nurse that thyroid hormone replacement therapy for hypothyroidism is effective? A:Declining thyroglobulin (Tg) levels; rising thyrotropin receptor antibody (TRAb) levels B: Declining thyroid hormone (TH) levels; rising thyroid-stimulating hormone (TSH) levels C: Rising thyroglobulin (Tg) levels; declining thyrotropin receptor antibody (TRAb) levels D: Rising thyroid hormone (TH) levels; declining thyroid-stimulating hormone (TSH) levels
D Drug therapy for hypothyroidism hormone replacement therapy with synthetic thyroid hormones, which would result in rising TH levels. As these levels rise, the negative feedback loop, which tries to stimulate the thyroid gland to produce TH would be suppressed, causes declining TSH levels. Thyroglobulin levels are related to active thyroid tissue. In hypothyroidism, these levels are low and drug therapy does not increase them. TRAbs are not a cause of hypothyroidism and do not develop with drug therapy.
Which question asked by a 48-year-old client with sleep apnea whose blood glucose level is elevated suggests to the nurse the possibility of a growth hormone excess? A: "Do you think if I lost weight my sleep apnea would improve?" B: "Why do I feel thirsty all the time?" C: "How can I make my skin less itchy?" D: "Does everyone's feet get bigger during menopause?"
D Growth hormone is secreted and is needed throughout the life span. When it is secreted in excess in adults, organs can enlarge and bones containing desmoid bone type increase in size, including the facial bones, hands, and feet. The other client questions are reasonable for a client with sleep apnea, hyperglycemia, and menopause to ask.
For which new-onset symptom or behavior will the nurse teach a client taking thyroid hormone replacement therapy (HRT) to report immediately to the primary health care provider? A: Calf muscle cramping B: Runny nose C: Anorexia D: Hand tremors
D Hand tremors are an indication of HRT toxicity with increased central nervous system stimulation. The dose must be decreased to prevent more serious neurologic and cardiac toxicities. Anorexia, runny nose, and muscle cramping are neither side effects of the drug nor indications of toxicity.
For which assessment finding in a client who had a transsphenoidal hypophysectomy yesterday will the nurse notify the primary health care provider immediately? A: Dry lips and oral mucosa on examination B: Nasal drainage that tests negative for glucose C: Urine specific gravity of 1.016 D: Client report of a headache and stiff neck
D Headache and stiff neck (nuchal rigidity) are symptoms of meningitis that have immediate implications for the client's care. The finding requires the nurse to immediately notify the primary health care provider. Dry lips and mouth are not unusual after surgery. Nasal drainage that tests negative for glucose is normal, expected, and not significant. A urine specific gravity of 1.016 is within normal limits.
What is the nurse's best response when family members of a client with hyperthyroidism express concern about the client's frequent mood swings? A: "Do the client's mood swings make you feel angry?" B: "The medications will make the mood swings disappear completely." C: "Your family member is sick. You must be patient." D: "Mood swings are common should diminish with treatment."
D Telling the family that the client's mood swings should diminish over time with treatment provides information to the family, as well as reassurance that this behavior is expected. Asking the family if the client's mood swings make them angry is a closed-ended question and could make the family members feel guilty. The response needs to be client-centered. Any medications or treatment may not completely remove the mood swings associated with hyperthyroidism. The family is aware that the client is sick. Telling them to be patient can also cause feelings of guilt and does not address the family's concerns.
What is the nurse's best response to a client newly diagnosed with diabetes who asks why he is always so thirsty? A: "Without insulin, glucose is excreted rather than used in the cells. The loss of glucose directly triggers thirst, especially for sugared drinks." B: "The extra glucose in the blood increases the blood sodium level, which increases your sense of thirst." C: "Without insulin, glucose combines with blood cholesterol, which damages the kidneys, making you feel thirsty even when no water has been lost." D: "The extra glucose in the blood makes the blood thicker, which then triggers thirst so that the water you drink will dilute the blood glucose level."
D The high blood glucose levels that are present, because movement of glucose into cells is impaired, increase the osmolarity of the blood. The increased osmolarity stimulates the osmoreceptors in the hypothalamus, which triggers the thirst reflex. In response, the person drinks more water (not sugary fluids or hyperosmotic fluids), which helps dilute blood glucose levels and reduces blood osmolarity.
Which action is most important for the nurse to take first after finding a client who has severe hypothyroidism to be unresponsive to attempts to waken her and have a heart rate of 46 beats/min? A: Increasing the IV infusion rate B: Initiating the Rapid Response Team C: Assessing temperature D: Applying oxygen by mask
D The most common cause of death with severe hypothyroidism is respiratory failure with decreased gas exchange. The nurse would apply oxygen first and then initiate the Rapid Response Team. Although a decreased body temperature would support the findings that a client with severe hypothyroidism is worsening, assessing it would not be helpful in this situation. Increasing the IV flow rate may not even improve cardiac output because the slow heart rate is not related to a volume deficit but to reduced myocardial contractility.
Which factor is most important for the nurse to assess before providing instruction to a client newly diagnosed with diabetes about the disease and its management? A: Current energy level and rest patterns B: Sexual orientation C: Current lifestyle for diet and exercise D: Education and literacy levels
D The most important factor for the nurse to determine before providing instruction to the newly diagnosed client with diabetes is the client's educational level and literacy level. A large amount of information must be synthesized. Written instructions are typically given. The client's ability to learn and read is essential to provide the client with instructions and information about diabetes. Although lifestyle would be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.
The nurse has just received report on a group of clients. Which client is the nurse's first priority? A: A 42 year old with diabetes insipidus who has a dose of desmopressin due. B: A 35 year old with hyperaldosteronism who has a serum potassium of 3.0 mEq/L (3.0 mmol/L). C: A 50 year old with pituitary adenoma who is reporting a severe headache. D: A 28 year old with acute adrenal insufficiency who has a blood glucose of 36 mg/dL (2.0 mmol/L).
D The nurse first attends to the client with adrenal insufficiency who has a blood glucose level of 36 mg/dL (2.0 mmol/L). The client's condition is considered a medical emergency and must be assessed and treated immediately. Although it is important to maintain prescribed drugs on schedule, especially when a client is demonstrating a need for the next dose, the client requiring a dose of desmopressin cannot take priority over treatment of severe hypoglycemia. A serum potassium of 3.0 mEq/L (3.0 mmol/L) in the client with hyperaldosteronism may be considered normal (or slightly hypokalemic) and does not require immediate attention. The client reporting a severe headache needs to be evaluated as soon as possible after the client with acute adrenal insufficiency.
The nurse assesses blood clots in a client's urinary catheter after a cystoscopy. What initial nursing intervention is appropriate? A: Administer heparin intravenously. B: Remove the urinary catheter. C: Irrigate the catheter with sterile saline. D: Notify the health care provider (HCP).
D The nurse first notifies the HCP after visualizing a blood clot in a postoperative cystoscopy client's urinary catheter. Bleeding and/or blood clots are potential complications of cystoscopy and may obstruct the catheter and decrease urine output. In addition, the nurse must monitor urine output and notify the HCP of obvious blood clots or a decreased or absent urine output.Heparin would not be administered due to bleeding. The urinary catheter is allowing close monitoring of the urinary system and would not be removed at this time. The Foley catheter may be irrigated with sterile saline if prescribed by the HCP.
Which action has the highest priority for the nurse to take when a client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." and has vital signs of: T 98.4° F (36.9° C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air? A: Administering oxygen B: Connecting a cardiac monitor C: Assessing arterial blood gas (ABG) values D: Assessing blood glucose level
D The nurse would first obtain the client's glucose level. Breathing deeply and stating, "I can't catch my breath" is indicative of Kussmaul respirations which is a sign of diabetic ketoacidosis (DKA).Based on the oxygen saturation, oxygen administration is not indicated. The diagnosis of DKA does not require ABGs. Cardiac monitoring may be implemented, but the first action would be to obtain the glucose level.
A client with chronic kidney disease asks the nurse about the relationship between the disease and high blood pressure. What is the most appropriate nursing response? A: "The damaged kidneys no longer release a hormone that prevents high blood pressure." B: "The waste products in the blood interfere with mechanisms that control blood pressure." C: "There is a compensatory mechanism that increases blood flow through the kidneys in an effort to get rid of some of the waste products." D: "Because the kidneys cannot get rid of fluid, blood pressure goes up.
D The nurse's best response to a client with chronic kidney disease and high blood pressure is, "Because the kidneys cannot get rid of fluid, blood pressure goes up." In chronic kidney disease, fluid levels increase in the circulatory system.The statements asserting that damaged kidneys no longer release a hormone to prevent high blood pressure, waste products in the blood interfere with other mechanisms controlling blood pressure, and high blood pressure is a compensatory mechanism that increases blood flow through the kidneys in attempt excrete waste products are not accurate regarding the relationship between chronic kidney disease and high blood pressure.
Which assessment finding in a client with diabetes mellitus indicates to the nurse that the disease is damaging the kidneys? A: White blood cells (WBCs) in the urine during a random urinalysis B: Ketone bodies in the urine during acidosis C: Glucose in the urine during hyperglycemia D: Protein in the urine during a random urinalysis
D Urine should not contain protein and the presence of proteinuria in a client with marks the beginning of renal problems known as diabetic nephropathy, that progresses eventually to end-stage renal disease. Chronically elevated blood glucose levels cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. The excess leakiness allows larger substances, such as proteins, to be filtered into the urine.
Which statement by a client indicates to the nurse correct understanding of what to do when the sensations of hunger and shakiness occur? A: "I will eat three graham crackers." B: "I will drink a glass of water." C: "I will sit down and rest." D: "I will give myself a dose of glucagon."
Feeling hungry and shaky are symptoms of mild hypoglycemia. Correct understanding of what the client needs to do when these symptoms occur is to eat three graham crackers. This is the correct management strategy for mild hypoglycemia. Drinking a glass of water or sitting down and resting does not remedy hypoglycemia. Glucagon is generally administered for episodes of severe not mild hypoglycemia.