CH 5958616468

A nurse prepares to administer prescribed regular and NPH insulin. Place the nurses actions in the correct order to administer these medications. 1. Inspect bottles for expiration dates. 2. Gently roll the bottle of NPH between the hands. 3. Wash your hands. 4. Inject air into the regular insulin. 5. Withdraw the NPH insulin. 6. Withdraw the regular insulin. 7. Inject air into the NPH bottle. 8. Clean rubber stoppers with an alcohol swab.

3, 1, 2, 8, 7, 4, 6, 5 It is important to inject air into the NPH bottle before placing the needle in a regular insulin bottle to avoid mixing of regular and NPH insulin. The shorter-acting insulin is always drawn up first.

A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? A 29-year-old Caucasian A 32-year-old African- American A 44-year-old Asian A 48-year-old American Indian

A 48-year-old American Indian Being both an American Indian and middle-aged places this client at highest risk.

An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.) a. Policies related to consistent use of Standard Precautions b. Hepatitis vaccination mandate for workers in high-risk areas c. Implementation of a needleless system for intravenous therapy d. Number of sharps used in client care reduced where possible e. Postexposure prophylaxis provided in a timely manner

A, C, D, E

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

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

A nurse plans care for a client who has acute pancreatitis and is prescribed nothing by mouth (NPO). With which health care team members should the nurse collaborate to provide appropriate nutrition to this client? (Select all that apply.) a. Registered dietitian b. Nursing assistant c. Clinical pharmacist d. Certified herbalist e. Health care provider

A,c,e

A nurse cares for a client with a deficiency of aldosterone. Which assessment finding should the nurse correlate with this deficiency? a. Increased urine output b. Vasoconstriction c. Blood glucose of 98 mg/dL d. Serum sodium of 144 mEq/L

A. Increased urine output Aldosterone, the major mineralocorticoid, maintains extracellular fluid volume. It promotes sodium and water reabsorption and potassium excretion in the kidney tubules. A client with an aldosterone deficiency will have increased urine output. Vasoconstriction is not related. These sodium and glucose levels are normal; in aldosterone deficiency, the client would have hyponatremia and hyperkalemia.

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

Administer 1 mg of intramuscular glucagon. The clients blood glucose level is dangerously low. The nurse needs to administer glucagon IM immediately to increase the clients blood glucose level. The nurse should insert a new IV after administering the glucagon and can use the new IV site for future doses of D50 if the clients blood glucose level does not rise. Once the client is awake, orange juice may be administered orally along with a form of protein such as a peanut butter.

A nurse teaches a client who is prescribed an insulin pump. Which statement should the nurse include in this clients discharge education? - Test your urine daily for ketones. - Use only buffered insulin in your pump. - Store the insulin in the freezer until you need it. - Change the needle every 3 days.

Change the needle every 3 days. Having the same needle remain in place through the skin for longer than 3 days drastically increases the risk for infection in or through the delivery system.

A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the clients breath has a fruity odor. Which action should the nurse take? Encourage the client to use an incentive spirometer. Increase the clients intravenous fluid flow rate. Consult the provider to test for ketoacidosis. Perform meticulous pulmonary hygiene care.

Consult the provider to test for ketoacidosis. The stress of surgery increases the action of counterregulatory hormones and suppresses the action of insulin, predisposing the client to ketoacidosis and metabolic acidosis. One manifestation of ketoacidosis is a fruity odor to the breath. Documentation should occur after all assessments have been completed.

A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect? a. Nausea and vomiting b. Frontal headache c. Vertigo and syncope d. Mid-sternal chest pain

D. Mid-sternal chest pain Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin.

A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) Deep and fast respirations Decreased urine output Tachycardia Dependent pulmonary crackles Orthostatic hypotension

Deep and fast respirations Tachycardia Orthostatic hypotension

After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? I should increase my intake of vegetables with higher amounts of dietary fiber. My intake of saturated fats should be no more than 10% of my total calorie intake. I should decrease my intake of protein and eliminate carbohydrates from my diet. My intake of water is not restricted by my treatment plan or medication regimen.

I should decrease my intake of protein and eliminate carbohydrates from my diet. The client should not completely eliminate carbohydrates from the diet, and should reduce protein if microalbuminuria is present. The client should increase dietary intake of complex carbohydrates, including vegetables, and decrease intake of fat. Water does not need to be restricted unless kidney failure is present.

After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? I have so many complications; exercising is not recommended. I will exercise more frequently because I have so many complications. I used to run for exercise; I will start training for a marathon. I should look into swimming or water aerobics to get my exercise.

I should look into swimming or water aerobics to get my exercise. Swimming or water aerobics will give the client exercise without the worry of having the correct shoes or developing a foot injury.

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

Increased rate and depth of respiration Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation.

A nurse reviews the medication list of a client recovering from a computed tomography (CT) scan with IV contrast to rule out small bowel obstruction. Which medication should alert the nurse to contact the provider and withhold the prescribed dose? Pioglitazone (Actos) Glimepiride (Amaryl) Glipizide (Glucotrol) Metformin (Glucophage)

Metformin (Glucophage) Glucophage should not be administered when the kidneys are attempting to excrete IV contrast from the body. This combination would place the client at high risk for kidney failure.

.A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? Urine specific gravity of 1.033 Presence of protein in the urine Elevated capillary blood glucose level Presence of ketone bodies in the urine

Presence of protein in the urine Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? Serum chloride level of 98 mmol/L Serum calcium level of 8.8 mg/dL Serum sodium level of 132 mmol/L Serum potassium level of 2.5 mmol/L

Serum potassium level of 2.5 mmol/L Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium.

A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) Stroke Kidney failure Blindness Respiratory failure Cirrhosis

Stroke Kidney failure Blindness

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this clients teaching to prevent injury? Examine your feet using a mirror every day. Rotate your insulin injection sites every week. Check your blood glucose level before each meal. Use a bath thermometer to test the water temperature.

Use a bath thermometer to test the water temperature. Clients with diminished sensory perception can easily experience a burn injury when bathwater is too hot. Instead of checking the temperature of the water by feeling it, they should use a thermometer.

A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this clients teaching to decrease the clients insulin needs? Limit your fluid intake to 2 liters a day. Animal organ meat is high in insulin. Limit your carbohydrate intake to 80 grams a day. Walk at a moderate pace for 1 mile daily.

Walk at a moderate pace for 1 mile daily. Moderate exercise such as walking helps regulate blood glucose levels on a daily basis and results in lowered insulin requirements for clients with type 1 diabetes mellitus.

A nurse cares for a client who has a family history of diabetes mellitus. The client states, My father has type 1 diabetes mellitus. Will I develop this disease as well? How should the nurse respond? a. Your risk of diabetes is higher than the general population, but it may not occur. b. No genetic risk is associated with the development of type 1 diabetes mellitus. c. The risk for becoming a diabetic is 50% because of how it is inherited. d. Female children do not inherit diabetes mellitus, but male children will.

Your risk of diabetes is higher than the general population, but it may not occur. Risk for type 1 diabetes is determined by inheritance of genes coding for HLA-DR and HLA-DQ tissue types. Clients who have one parent with type 1 diabetes are at increased risk for its development.

A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B? a. A 20-year-old college student who has had several sexual partners b. A 46-year-old woman who takes acetaminophen daily for headaches c. A 63-year-old businessman who travels frequently across the country d. An 82-year-old woman who recently ate raw shellfish for dinner

a. A 20-year-old college student who has had several sexual partners Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route.

client is undergoing hemodialysis. The clients blood pressure at the beginning of the procedure was 136/88 mm Hg, and now it is 110/54 mm Hg. What actions should the nurse perform to maintain blood pressure? (Select all that apply.) a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. c. Stop the hemodialysis treatment. d. Administer a 250-mL bolus of normal saline. e. Contact the health care provider for orders.

a. Adjust the rate of extracorporeal blood flow. b. Place the client in the Trendelenburg position. d. Administer a 250-mL bolus of normal saline.

A nurse prepares to administer insulin to a client at 1800. The clients medication administration record contains the following information: Insulin glargine: 12 units daily at 1800 Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 Based on the clients medication administration record, which action should the nurse take? a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. b. Draw up and inject the insulin glargine first, wait 20 minutes, and then draw up and inject the regular insulin. c. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. d. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.

a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. Insulin glargine must not be diluted or mixed with any other insulin or solution. Mixing results in an unpredictable alteration in the onset of action and time to peak action. The correct instruction is to draw up and inject first the glargine and then the regular insulin right afterward.

A client is hospitalized in the oliguric phase of acute kidney injury (AKI) and is receiving tube feedings. The nurse is teaching the clients spouse about the kidney-specific formulation for the enteral solution compared to standard formulas. What components should be discussed in the teaching plan? (Select all that apply.) a. Lower sodium b. Higher calcium c. Lower potassium d. Higher phosphorus e. Higher calories

a. Lower sodium c. Lower potassium e. Higher calories

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this clients plan of care to delay the onset of microvascular and macrovascular complications? a. Maintain tight glycemic control and prevent hyperglycemia. b. Restrict your fluid intake to no more than 2 liters a day. c. Prevent hypoglycemia by eating a bedtime snack. d. Limit your intake of protein to prevent ketoacidosis.

a. Maintain tight glycemic control and prevent hyperglycemia. Hyperglycemia is a critical factor in the pathogenesis of long-term diabetic complications. Maintaining tight glycemic control will help delay the onset of complications.

The nurse is caring for five clients on the medical-surgical unit. Which clients would the nurse consider to be at risk for post-renal acute kidney injury (AKI)? (Select all that apply.) a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis d. Firefighter with severe burns e. Young woman with lupus

a. Man with prostate cancer b. Woman with blood clots in the urinary tract c. Client with ureterolithiasis Urine flow obstruction, such as prostate cancer, blood clots in the urinary tract, and kidney stones (ureterolithiasis), causes post-renal AKI.

A client is taking furosemide (Lasix) 40 mg/day for management of chronic kidney disease (CKD). To detect the positive effect of the medication, what action of the nurse is best? a. Obtain daily weights of the client. b. Auscultate heart and breath sounds. c. Palpate the clients abdomen. d. Assess the clients diet history.

a. Obtain daily weights of the client. One kilogram of weight equals about 1 liter of fluid retained in the client, so daily weights are necessary to monitor the response of the client to the medication.

A client has a serum potassium level of 6.5 mmol/L, a serum creatinine level of 2 mg/dL, and a urine output of 350 mL/day. What is the best action by the nurse? a. Place the client on a cardiac monitor immediately. b. Teach the client to limit high-potassium foods. c. Continue to monitor the clients intake and output. d. Ask to have the laboratory redraw the blood specimen.

a. Place the client on a cardiac monitor immediately. The priority action by the nurse should be to check the cardiac status with a monitor. High potassium levels can lead to dysrhythmias.

A nurse is caring for a postoperative 70-kg client who had major blood loss during surgery. Which findings by the nurse should prompt immediate action to prevent acute kidney injury? (Select all that apply.) a. Urine output of 100 mL in 4 hours b. Urine output of 500 mL in 12 hours c. Large amount of sediment in the urine d. Amber, odorless urine e. Blood pressure of 90/60 mm Hg

a. Urine output of 100 mL in 4 hours c. Large amount of sediment in the urine e. Blood pressure of 90/60 mm Hg The low urine output, sediment, and blood pressure should be reported to the provider. Postoperatively, the nurse should measure intake and output, check the characteristics of the urine, and report sediment, hematuria, and urine output of less than 0.5 mL/kg/hour for 3 to 4 hours. A urine output of 100 mL is low, but a urine output of 500 mL in 12 hours should be within normal limits. Perfusion to the kidneys is compromised with low blood pressure. The amber odorless urine is normal.

A client is unsure of the decision to undergo peritoneal dialysis (PD) and wishes to discuss the advantages of this treatment with the nurse. Which statements by the nurse are accurate regarding PD? (Select all that apply.) a. You will not need vascular access to perform PD. b. There is less restriction of protein and fluids. c. You will have no risk for infection with PD. d. You have flexible scheduling for the exchanges. e. It takes less time than hemodialysis treatments.

a. You will not need vascular access to perform PD. b. There is less restriction of protein and fluids. d. You have flexible scheduling for the exchanges.

A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m2 f. 28-year-old female who gave birth to a baby weighing 9.2 pounds

a.d.e.f

A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300

b. 1600 Neutral protamine Hagedorn (NPH) is an intermediate-acting insulin with an onset of 1.5 hours, peak of 4 to 12 hours, and duration of action of 22 hours. Checking the client at 0800 would be too soon. Checking the client at 2000 and 2300 would be too late. The nurse should check the client at 1600.

A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)? a. Have the client sign the informed consent form. b. Assist the client to void before the procedure. c. Help the client lie flat in bed on the right side. d. Get the client into a chair after the procedure.

b. Assist the client to void before the procedure. For safety, the client should void just before a paracentesis.

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort? a. Administer morphine sulfate intravenously every 4 hours as needed. b. Maintain nothing by mouth (NPO) and administer intravenous fluids. c. Provide small, frequent feedings with no concentrated sweets. d. Place the client in semi-Fowlers position with the head of bed elevated.

b. Maintain nothing by mouth (NPO) and administer intravenous fluids. The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production.

A nurse teaches a client who is recovering from acute pancreatitis. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Take a 20-minute walk at least 5 days each week. b. Attend local Alcoholics Anonymous (AA) meetings weekly. c. Choose whole grains rather than foods with simple sugars. d. Use cooking spray when you cook rather than margarine or butter. e. Stay away from milk and dairy products that contain lactose. f. We can talk to your doctor about a prescription for nicotine patches.

b. Attend local Alcoholics Anonymous (AA) meetings weekly. d. Use cooking spray when you cook rather than margarine or butter f. We can talk to your doctor about a prescription for nicotine patches.

The nurse is caring for four clients with chronic kidney disease. Which client should the nurse assess first upon initial rounding? a. Woman with a blood pressure of 158/90 mm Hg b. Client with Kussmaul respirations c. Man with skin itching from head to toe d. Client with halitosis and stomatitis

b. Client with Kussmaul respirations Kussmaul respirations indicate a worsening of chronic kidney disease (CKD). The client is increasing the rate and depth of breathing to excrete carbon dioxide through the lungs

The nurse is teaching the main principles of hemodialysis to a client with chronic kidney disease. Which statement by the client indicates a need for further teaching by the nurse? a. My sodium level changes by movement from the blood into the dialysate. b. Dialysis works by movement of wastes from lower to higher concentration. c. Extra fluid can be pulled from the blood by osmosis. d. The dialysate is similar to blood but without any toxins.

b. Dialysis works by movement of wastes from lower to higher concentration. Dialysis works using the passive transfer of toxins by diffusion. Diffusion is the movement of molecules from an area of higher concentration to an area of lower concentration. The other statements show a correct understanding about hemodialysis.

A client is admitted with acute kidney injury (AKI) and a urine output of 2000 mL/day. What is the major concern of the nurse regarding this clients care? a. Edema and pain b. Electrolyte and fluid imbalance c. Cardiac and respiratory status d. Mental health status

b. Electrolyte and fluid imbalance This client may have an inflammatory cause of AKI with proteins entering the glomerulus and holding the fluid in the filtrate, causing polyuria. Electrolyte loss and fluid balance is essential.

A nurse is giving discharge instructions to a client recently diagnosed with chronic kidney disease (CKD). Which statements made by the client indicate a correct understanding of the teaching? (Select all that apply.) a. I can continue to take antacids to relieve heartburn. b. I need to ask for an antibiotic when scheduling a dental appointment. c. Ill need to check my blood sugar often to prevent hypoglycemia. d. The dose of my pain medication may have to be adjusted. e. I should watch for bleeding when taking my anticoagulants.

b. I need to ask for an antibiotic when scheduling a dental appointment. c. Ill need to check my blood sugar often to prevent hypoglycemia. d. The dose of my pain medication may have to be adjusted. e. I should watch for bleeding when taking my anticoagulants.

A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client? a. I drink two glasses of red wine each week. b. I take a lot of Tylenol for my arthritis pain. c. I have a cousin who died of liver cancer. d. I got a hepatitis vaccine before traveling.

b. I take a lot of Tylenol for my arthritis pain. ANS: B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen.

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: Vital Signs and Assessment: 90/62 mm Hg, 120 beats/min, 28 breaths/min Urine output: 20 mL/hr via catheter Laboratory Results: potassium: 2.6 mEq/L Medications: Potassium chloride 40 mEq IV bolus STAT, Increase IV fluid to 100 mL/hr Which action should the nurse take? a. Administer the potassium and then consult with the provider about the fluid order. b. Increase the intravenous rate and then consult with the provider about the potassium prescription. c. Administer the potassium first before increasing the infusion flow rate. d. Increase the intravenous flow rate before administering the potassium

b. Increase the intravenous rate and then consult with the provider about the potassium prescription. The client is acutely ill and is severely dehydrated and hypokalemic. The client requires more IV fluids and potassium. However, potassium should not be infused unless the urine output is at least 30 mL/hr. The nurse should first increase the IV rate and then consult with the provider about the potassium.

A nurse collaborates with an unlicensed assistive personnel (UAP) to provide care for a client who is in the healing phase of acute pancreatitis. Which statements focused on nutritional requirements should the nurse include when delegating care for this client? (Select all that apply.) a. Do not allow the client to eat between meals. b. Make sure the client receives a protein shake. c. Do not allow caffeine-containing beverages. d. Make sure the foods are bland with little spice. e. Do not allow high-carbohydrate food items.

b. Make sure the client receives a protein shake. c. Do not allow caffeine-containing beverages. d. Make sure the foods are bland with little spice.

The nurse is teaching a client with diabetes mellitus how to prevent or delay chronic kidney disease (CKD). Which client statements indicate a lack of understanding of the teaching? (Select all that apply.) a. I need to decrease sodium, cholesterol, and protein in my diet. b. My weight should be maintained at a body mass index of 30. c. Smoking should be stopped as soon as I possibly can .d. I can continue to take an aspirin every 4 to 8 hours for my pain. e. I really only need to drink a couple of glasses of water each day.

b. My weight should be maintained at a body mass index of 30. d. I can continue to take an aspirin every 4 to 8 hours for my pain. e. I really only need to drink a couple of glasses of water each day.

The nurse is assessing a client with a diagnosis of pre-renal acute kidney injury (AKI). Which condition would the nurse expect to find in the clients recent history? a. Pyelonephritis b. Myocardial infarction c. Bladder cancer d. Kidney stones

b. Myocardial infarction Pre-renal causes of AKI are related to a decrease in perfusion, such as with a myocardial infarction.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.

b. Provide a low-sodium diet. A low-sodium diet is one means of controlling abdominal fluid collection.

A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, I am experiencing right flank pain and have a temperature of 101 F. How should the nurse respond? a. The anti-rejection drugs you are taking make you susceptible to infection. b. You should go to the hospital immediately to have your new liver checked out. c. You should take an additional dose of cyclosporine today. d. Take acetaminophen (Tylenol) every 4 hours until you feel better.

b. You should go to the hospital immediately to have your new liver checked out. Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention.

A client is diagnosed with chronic kidney disease (CKD). What is an ideal goal of treatment set by the nurse in the care plan to reduce the risk of pulmonary edema? a. Maintaining oxygen saturation of 89% b. Minimal crackles and wheezes in lung sounds c. Maintaining a balanced intake and output d. Limited shortness of breath upon exertion

c . Maintaining a balanced intake and output

A nurse assesses clients at a community health center. Which client is at highest risk for pancreatic cancer? a. A 32-year-old with hypothyroidism b. A 44-year-old with cholelithiasis c. A 50-year-old who has the BRCA2 gene mutation d. A 68-year-old who is of African-American ethnicity

c. A 50-year-old who has the BRCA2 gene mutation Mutations in both the BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a small number of cases. The other factors do not appear to be linked to increased risk.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver? a. A 22-year-old with a history of blunt liver trauma b. A 48-year-old with a history of diabetes mellitus c. A 66-year-old who has a history of cirrhosis d. An 82-year-old who has chronic malnutrition

c. A 66-year-old who has a history of cirrhosis The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause.

The charge nurse is orienting a float nurse to an assigned client with an arteriovenous (AV) fistula for hemodialysis in her left arm. Which action by the float nurse would be considered unsafe? a. Palpating the access site for a bruit or thrill b. Using the right arm for a blood pressure reading c. Administering intravenous fluids through the AV fistula d. Checking distal pulses in the left arm

c. Administering intravenous fluids through the AV fistula The nurse should not use the arm with the AV fistula for intravenous infusion, blood pressure readings, or venipuncture. Compression and infection can result in the loss of the AV fistula. The AV fistula should be monitored by auscultating or palpating the access site. Checking the distal pulse would be an appropriate assessment.

A nurse prepares to assess the emotional state of a client with end-stage pancreatic cancer. Which action should the nurse take first? a. Bring the client to a quiet room for privacy. b. Pull up a chair and sit next to the clients bed. c. Determine whether the client feels like talking about his or her feelings. d. Review the health care providers notes about the prognosis for the client.

c. Determine whether the client feels like talking about his or her feelings. Before conducting an assessment about the clients feelings, the nurse should determine whether he or she is willing and able to talk about them.

A nurse cares for a client with acute pancreatitis. The client states, I am hungry. How should the nurse reply? a. Is your stomach rumbling or do you have bowel sounds? b. I need to check your gag reflex before you can eat. c. Have you passed any flatus or moved your bowels? d. You will not be able to eat until the pain subsides.

c. Have you passed any flatus or moved your bowels? Paralytic ileus is a common complication of acute pancreatitis.

After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the clients understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching? a. I should drink bottled water during my travels. b. I will not eat off anothers plate or share utensils. c. I should eat plenty of fresh fruits and vegetables. d. I will wash my hands frequently and thoroughly.

c. I should eat plenty of fresh fruits and vegetables. The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water.

The nurse is teaching a client how to increase the flow of dialysate into the peritoneal cavity during dialysis. Which statement by the client demonstrates a correct understanding of the teaching? a. I should leave the drainage bag above the level of my abdomen. b. I could flush the tubing with normal saline if the flow stops. c. I should take a stool softener every morning to avoid constipation. d. My diet should have low fiber in it to prevent any irritation.

c. I should take a stool softener every morning to avoid constipation. Inflow and outflow problems of the dialysate are best controlled by preventing constipation. A daily stool softener is the best option for the client.

A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, All of my family hates me. How should the nurse respond? a. You should make peace with your family. b. This is not unusual. My family hates me too. c. I will help you identify a support system. d. You must attend Alcoholics Anonymous.

c. I will help you identify a support system.

A nurse reviews these laboratory values of a client who returned from kidney transplantation 12 hours ago: Sodium 136 mEq/L Potassium 5 mEq/L Blood urea nitrogen (BUN) 44 mg/dL Serum creatinine 2.5 mg/dL What initial intervention would the nurse anticipate? a. Start hemodialysis immediately. b. Discuss the need for peritoneal dialysis. c. Increase the dose of immunosuppression. d. Return the client to surgery for exploration.

c. Increase the dose of immunosuppression. The client may need a higher dose of immunosuppressive medication as evidenced by the elevated BUN and serum creatinine levels.

The nurse is taking the vital signs of a client after hemodialysis. Blood pressure is 110/58 mm Hg, pulse 66 beats/min, and temperature is 99.8 F (37.6 C). What is the most appropriate action by the nurse? a. Administer fluid to increase blood pressure. b. Check the white blood cell count. c. Monitor the clients temperature. d. Connect the client to an electrocardiographic (ECG) monitor.

c. Monitor the clients temperature. During hemodialysis, the dialysate is warmed to increase diffusion and prevent hypothermia. The clients temperature could reflect the temperature of the dialysate.

A client is placed on fluid restrictions because of chronic kidney disease (CKD). Which assessment finding would alert the nurse that the clients fluid balance is stable at this time? a. Decreased calcium levels b. Increased phosphorus levels c. No adventitious sounds in the lungs d. Increased edema in the legs

c. No adventitious sounds in the lungs The absence of adventitious sounds upon auscultation of the lungs indicates a lack of fluid overload and fluid balance in the clients body.

The charge nurse of the medical-surgical unit is making staff assignments. Which staff member should be assigned to a client with chronic kidney disease who is exhibiting a low-grade fever and a pericardial friction rub? a. Registered nurse who just floated from the surgical unit b. Registered nurse who just floated from the dialysis unit c. Registered nurse who was assigned the same client yesterday d. Licensed practical nurse with 5 years experience on this floor

c. Registered nurse who was assigned the same client yesterday

After teaching a client who is prescribed pancreatic enzyme replacement therapy, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. The capsules can be opened and the powder sprinkled on applesauce if needed. b. I will wipe my lips carefully after I drink the enzyme preparation. c. The best time to take the enzymes is immediately after I have a meal or a snack. d. I will not mix the enzyme powder with food or liquids that contain protein.

c. The best time to take the enzymes is immediately after I have a meal or a snack. The enzymes should be taken immediately before eating meals or snacks.

A client has a long history of hypertension. Which category of medications would the nurse expect to be ordered to avoid chronic kidney disease (CKD)? a. Antibiotic b. Histamine blocker c. Bronchodilator d. Angiotensin-converting enzyme (ACE) inhibitor

d. Angiotensin-converting enzyme (ACE) inhibitor ACE inhibitors stop the conversion of angiotensin I to the vasoconstrictor angiotensin II. This category of medication also blocks bradykinin and prostaglandin, increases renin, and decreases aldosterone, which promotes vasodilation and perfusion to the kidney.

After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. At my age, I should continue seeing the ophthalmologist as I usually do. b. I will see the eye doctor when I have a vision problem and yearly after age 40. c. My vision will change quickly. I should see the ophthalmologist twice a year. d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.

d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.

A nurse is caring for a client who is scheduled for a dose of cefazolin and vitamins at this time. Hemodialysis for this client is also scheduled in 60 minutes. Which action by the nurse is best? a. Administer cefazolin since the level of the antibiotic must be maintained. b. Hold the vitamins but administer the cefazolin. c. Hold the cefazolin but administer the vitamins. d. Hold all medications since both cefazolin and vitamins are dialyzable.

d. Hold all medications since both cefazolin and vitamins are dialyzable.

A client has just had a central line catheter placed that is specific for hemodialysis. What is the most appropriate action by the nurse? a. Use the catheter for the next laboratory blood draw. b. Monitor the central venous pressure through this line. c. Access the line for the next intravenous medication. d. Place a heparin or heparin/saline dwell after hemodialysis.

d. Place a heparin or heparin/saline dwell after hemodialysis.

A client with acute kidney injury has a blood pressure of 76/55 mm Hg. The health care provider ordered 1000 mL of normal saline to be infused over 1 hour to maintain perfusion. The client is starting to develop shortness of breath. What is the nurses priority action? a. Calculate the mean arterial pressure (MAP). b. Ask for insertion of a pulmonary artery catheter. c. Take the clients pulse. d. Slow down the normal saline infusion.

d. Slow down the normal saline infusion. The nurse should assess that the client could be developing fluid overload and respiratory distress and slow down the normal saline infusion.

A client with chronic kidney disease states, I feel chained to the hemodialysis machine. What is the nurses best response to the clients statement? a. That feeling will gradually go away as you get used to the treatment. b. You probably need to see a psychiatrist to see if you are depressed. c. Do you need help from social services to discuss financial aid? d. Tell me more about your feelings regarding hemodialysis treatment.

d. Tell me more about your feelings regarding hemodialysis treatment.

When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, I will never be able to stick myself with a needle. How should the nurse respond? a. I can give your injections to you while you are here in the hospital. b. Everyone gets used to giving themselves injections. It really does not hurt. c. Your disease will not be managed properly if you refuse to administer the shots. d. Tell me what it is about the injections that are concerning you.

d. Tell me what it is about the injections that are concerning you.

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values should the nurse identify as potential ketoacidosis in this client? a. pH 7.38, HCO3 22 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg b. pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg c. pH 7.48, HCO3 28 mEq/L, PCO2 38 mm Hg, PO2 98 mm Hg d. pH 7.32, HCO3 22 mEq/L, PCO2 58 mm Hg, PO2 88 mm Hg

pH 7.28, HCO3 18 mEq/L, PCO2 28 mm Hg, PO2 98 mm Hg When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

A nurse cares for a client who has type 1 diabetes mellitus. The client asks, Is it okay for me to have an occasional glass of wine? How should the nurse respond? Drinking any wine or alcohol will increase your insulin requirements. Because of poor kidney function, people with diabetes should avoid alcohol. You should not drink alcohol because it will make you hungry and overeat. One glass of wine is okay with a meal and is counted as two fat exchanges.

One glass of wine is okay with a meal and is counted as two fat exchanges. Under normal circumstances, blood glucose levels will not be affected by moderate use of alcohol when diabetes is well controlled. Because alcohol can induce hypoglycemia, it should be ingested with or shortly after a meal.

A nurse cares for a client who is prescribed pioglitazone (Actos). After 6 months of therapy, the client reports that his urine has become darker since starting the medication. Which action should the nurse take? Assess for pain or burning with urination. Review the clients liver function study results. Instruct the client to increase water intake. Test a sample of urine for occult blood.

Review the clients liver function study results. Thiazolidinediones (including pioglitazone) can affect liver function; liver function should be assessed at the start of therapy and at regular intervals while the client continues to take these drugs. Dark urine is one indicator of liver impairment because bilirubin is increased in the blood and is excreted in the urine. The nurse should check the clients most recent liver function studies.

A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond? - Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up. - Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light. - Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes. - No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.

Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up. Insulin is relatively stable when stored in a cool, dry place away from light. When refrigerated, prefilled plastic syringes are stable for up to 3 weeks.

A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.) a. Apply lotion to the clients dry skin areas. b. Use a basin with warm water to bathe the client. c. For the clients oral care, use a soft toothbrush. d. Provide clippers so the client can trim the fingernails. e. Bathe with antibacterial and water-based soaps.

a. Apply lotion to the clients dry skin areas. c. For the clients oral care, use a soft toothbrush. d. Provide clippers so the client can trim the fingernails.

A client with chronic kidney disease (CKD) is experiencing nausea, vomiting, visual changes, and anorexia. Which action by the nurse is best? a. Check the clients digoxin (Lanoxin) level. b. Administer an anti-nausea medication. c. Ask if the client is able to eat crackers. d. Get a referral to a gastrointestinal provider.

a. Check the clients digoxin (Lanoxin) level. These signs and symptoms are indications of digoxin (Lanoxin) toxicity. The nurse should check the level of this medication.

A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, I do not want to take this medication because it causes diarrhea. How should the nurse respond? a. Diarrhea is expected; thats how your body gets rid of ammonia. b. You may take Kaopectate liquid daily for loose stools. c. Do not take any more of the medication until your stools firm up. d. We will need to send a stool specimen to the laboratory.

a. Diarrhea is expected; thats how your body gets rid of ammonia. The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant.

The nurse is teaching a client with chronic kidney disease (CKD) about the sodium restriction needed in the diet to prevent edema and hypertension. Which statement by the client indicates more teaching is needed? a. I am thrilled that I can continue to eat fast food. b. I will cut out bacon with my eggs every morning. c. My cooking style will change by not adding salt. d. I will probably lose weight by cutting out potato chips.

a. I am thrilled that I can continue to eat fast food.

A nurse cares for a client with end-stage pancreatic cancer. The client asks, Why is this happening to me? How should the nurse respond? a. I dont know. I wish I had an answer for you, but I dont. b. Its important to keep a positive attitude for your family right now. c. Scientists have not determined why cancer develops in certain people. d. I think that this is a trial so you can become a better person because of it.

a. I dont know. I wish I had an answer for you, but I dont. The client is not asking the nurse to actually explain why the cancer has occurred.

A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.) a. Elevated aspartate transaminase b. Elevated international normalized ratio (INR) c. Decreased serum globulin levels d. Decreased serum alkaline phosphatase e. Elevated serum ammonia f. Elevated prothrombin time (PT)

b. Elevated international normalized ratio (INR) e. Elevated serum ammonia f. Elevated prothrombin time (PT) Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the clients confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

A nurse reviews laboratory results for a client with diabetes mellitus who is prescribed an intensified insulin regimen: Fasting blood glucose: 75 mg/dL Postprandial blood glucose: 200 mg/dL Hemoglobin A1c level: 5.5% How should the nurse interpret these laboratory findings? a. Increased risk for developing ketoacidosis b. Good control of blood glucose c. Increased risk for developing hyperglycemia d. Signs of insulin resistance

b. Good control of blood glucose The client is maintaining blood glucose levels within the defined ranges for goals in an intensified regimen. Because the clients glycemic control is good, he or she is not at higher risk for ketoacidosis or hyperglycemia and is not showing signs of insulin resistance.

A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond? a. A low-protein diet will help the liver rest and will restore liver function. b. Less protein in the diet will help prevent confusion associated with liver failure. c. Increasing dietary protein will help the client gain weight and muscle mass. d. Low dietary protein is needed to prevent fluid from leaking into the abdomen.

b. Less protein in the diet will help prevent confusion associated with liver failure. A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia.

A nurse cares for a client with pancreatic cancer who is prescribed implanted radioactive iodine seeds. Which actions should the nurse take when caring for this client? (Select all that apply.) a. Dispose of dirty linen in a red biohazard bag. b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client. e. Initiate Transmission-Based Precautions.

b. Place the client in a private room. c. Wear a lead apron when providing client care. d. Bundle care to minimize exposure to the client.

A nurse develops a dietary plan for a client with diabetes mellitus and new-onset microalbuminuria. Which component of the clients diet should the nurse decrease? a. Carbohydrates b. Proteins c. Fats d. Total calories

b. Proteins Restriction of dietary protein to 0.8 g/kg of body weight per day is recommended for clients with microalbuminuria to delay progression to renal failure. The clients diet does not need to be decreased in carbohydrates, fats, or total calories.

An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.) a. Hypertension b. Tachycardia c. Flushed skin d. Confusion e. Shallow respirations

b. Tachycardia d. Confusion Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion.

A client is recovering from a kidney transplant. The clients urine output was 1500 mL over the last 12-hour period since transplantation. What is the priority assessment by the nurse? a. Checking skin turgor b. Taking blood pressure c. Assessing lung sounds d. Weighing the client

b. Taking blood pressure By taking blood pressure, the nurse is assessing for hypotension that could compromise perfusion to the new kidney.

A nurse cares for a client with hepatitis C. The clients brother states, I do not want to contract this infection, so I will not go into his hospital room. How should the nurse respond? a. If you wear a gown and gloves, you will not get this virus. b. Viral hepatitis is not spread through casual contact. c. This virus is only transmitted through a fecal specimen. d. I can give you an update on your brothers status from here.

b. Viral hepatitis is not spread through casual contact. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia.

A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? - Document the finding in the clients chart. - Assess tactile sensation in the clients hands. - Examine the clients feet for signs of injury. - Notify the health care provider.

- Examine the clients feet for signs of injury.

A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the clients clinical manifestations have not changed. Which action should the nurse take next? Administer another half-cup of orange juice. Administer a half-ampule of dextrose 50% intravenously. Administer 10 units of regular insulin subcutaneously. Administer 1 mg of glucagon intramuscularly.

Administer another half-cup of orange juice. This client is experiencing mild hypoglycemia. For mild hypoglycemic manifestations, the nurse should administer oral glucose in the form of orange juice. If the symptoms do not resolve immediately, the treatment should be repeated. The client does not need intravenous dextrose, insulin, or glucagon.

A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this clients teaching? - Change positions slowly when you get out of bed. - Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs). - If you miss a dose of this drug, you can double the next dose. - Discontinue the medication if you develop a urinary infection

Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs potentiate the hypoglycemic effects of sulfonylurea agents. Glipizide is a sulfonylurea. The other statements are not applicable to glipizide.

After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. Some medications have been known to cause hepatitis A. b. I may have been exposed when we ate shrimp last weekend. c. I was infected with hepatitis A through a recent blood transfusion. d. My infection with Epstein-Barr virus can co-infect me with hepatitis

B. I may have been exposed when we ate shrimp last weekend. The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish.

A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this clients teaching? (Select all that apply.) Do not walk around barefoot. Soak your feet in a tub each evening. Trim toenails straight across with a nail clipper. Treat any blisters or sores with Epsom salts. Wash your feet every other day.

Do not walk around barefoot. Trim toenails straight across with a nail clipper.

A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The clients blood glucose level is 160 mg/dL. Which action should the nurse take? Document the finding in the clients chart. Administer a bolus of regular insulin IV. Call the surgeon to cancel the procedure. Draw blood gases to assess the metabolic state.

Document the finding in the clients chart. Clients who have type 1 diabetes and are having surgery have been found to have fewer complications, lower rates of infection, and better wound healing if blood glucose levels are maintained at between 140 and 180 mg/dL throughout the perioperative period.

A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? Serum potassium level has increased. Blood osmolarity has decreased. Glasgow Coma Scale score is unchanged. Urine remains negative for ketone bodies.

Glasgow Coma Scale score is unchanged. A slow but steady improvement in central nervous system functioning is the best indicator of therapy effectiveness for HHS. Lack of improvement in the level of consciousness may indicate inadequate rates of fluid replacement.

After teaching a client with type 2 diabetes mellitus who is prescribed nateglinide (Starlix), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the prescribed therapy? - Ill take this medicine during each of my meals. - I must take this medicine in the morning when I wake. - I will take this medicine before I go to bed. - I will take this medicine immediately before I eat.

I will take this medicine immediately before I eat. Nateglinide is an insulin secretagogue that is designed to increase meal-related insulin secretion. It should be taken immediately before each meal. The medication should not be taken without eating as it will decrease the clients blood glucose levels. The medication should be taken before meals instead of during meals.

After teaching a client who is recovering from pancreas transplantation, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional education? If I develop an infection, I should stop taking my corticosteroid. If I have pain over the transplant site, I will call the surgeon immediately. I should avoid people who are ill or who have an infection. I should take my cyclosporine exactly the way I was taught.

If I develop an infection, I should stop taking my corticosteroid. Immunosuppressive agents should not be stopped without the consultation of the transplantation physician, even if an infection is present. Stopping immunosuppressive therapy endangers the transplanted organ. The other statements are correct. Pain over the graft site may indicate rejection. Anti-rejection drugs cause immunosuppression, and the client should avoid crowds and people who are ill. Changing the routine of anti- rejection medications may cause them to not work optimally.

A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? Apply ice to the site to reduce inflammation. Consult the provider for a new administration route. Assess the client for other signs of cellulitis. Instruct the client to rotate sites for insulin injection.

Instruct the client to rotate sites for insulin injection. The clients tissue has been damaged from continuous use of the same site. The client should be educated to rotate sites.

A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone! Which action should the nurse take? a. Instruct the client to sit in as upright a position as possible. b. Add humidity to the oxygen and encourage the client to wear it. c. Document the clients refusal, and call the health care provider. d. Contact the provider to request an extra dose of the clients diuretic.

Instruct the client to sit in as upright a position as possible. The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that.

A nurse cares for a client who is diagnosed with acute rejection 2 months after receiving a simultaneous pancreas-kidney transplant. The client states, I was doing so well with my new organs, and the thought of having to go back to living on hemodialysis and taking insulin is so depressing. How should the nurse respond? Following the drug regimen more closely would have prevented this. One acute rejection episode does not mean that you will lose the new organs. Dialysis is a viable treatment option for you and may save your life. Since you are on the national registry, you can receive a second transplantation.

One acute rejection episode does not mean that you will lose the new organs An episode of acute rejection does not automatically mean that the client will lose the transplant. Pharmacologic manipulation of host immune responses at this time can limit damage to the organ and allow the graft to be maintained.

A nurse cares for a client who has obstructive jaundice. The client asks, Why is my skin so itchy? How should the nurse respond? a. Bile salts accumulate in the skin and cause the itching. b. Toxins released from an inflamed gallbladder lead to itching. c. Itching is caused by the release of calcium into the skin. d. Itching is caused by a hypersensitivity reaction.

a. Bile salts accumulate in the skin and cause the itching. In obstructive jaundice, the normal flow of bile into the duodenum is blocked, allowing excess bile salts to accumulate on the skin. This leads to itching, or pruritus. The other statements are not accurate.

A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse? a. Discuss what the treatment regimen means to him. b. Refer the client to a mental health nurse practitioner. c. Reschedule the appointments to another date and time. d. Discuss the option of peritoneal dialysis.

a. Discuss what the treatment regimen means to him.

A nurse prepares to discharge a client with chronic pancreatitis. Which question should the nurse ask to ensure safety upon discharge? a. Do you have a one- or two-story home? b. Can you check your own pulse rate? c. Do you have any alcohol in your home? d. Can you prepare your own meals?

a. Do you have a one- or two-story home? A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase.

A marathon runner comes into the clinic and states I have not urinated very much in the last few days. The nurse notes a heart rate of 110 beats/min and a blood pressure of 86/58 mm Hg. Which action by the nurse is the priority? a. Give the client a bottle of water immediately. b. Start an intravenous line for fluids. c. Teach the client to drink 2 to 3 liters of water daily. d. Perform an electrocardiogram.

a. Give the client a bottle of water immediately. This athlete is mildly dehydrated as evidenced by the higher heart rate and lower blood pressure.

A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse? a. Urine output via indwelling urinary catheter is 20 mL/hr b. Blood pressure increases from 110/58 to 120/62 mm Hg c. Respiratory rate decreases from 18 to 14 breaths/min d. A decrease in the clients weight by 6 kg

a. Urine output via indwelling urinary catheter is 20 mL/hr Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr.

A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this clients discharge education? a. Use a pill organizer to ensure you take this medication as prescribed. b. Transient muscle aching is a common side effect of this medication. c. Follow up with your provider in 1 week to test your blood for toxicity. d. Take your radial pulse for 1 minute prior to taking this medication.

a. Use a pill organizer to ensure you take this medication as prescribed. Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time.

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I cannot drink any alcohol at all anymore. b. I need to avoid protein in my diet. c. I should not take over-the-counter medications. d. I should eat small, frequent, balanced meals.

b. I need to avoid protein in my diet. Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing.

A client is having a peritoneal dialysis treatment. The nurse notes an opaque color to the effluent. What is the priority action by the nurse?a. Warm the dialysate solution in a microwave before instillation .b. Take a sample of the effluent and send to the laboratory. c. Flush the tubing with normal saline to maintain patency of the catheter. d. Check the peritoneal catheter for kinking and curling.

.b. Take a sample of the effluent and send to the laboratory. An opaque or cloudy effluent is the first sign of peritonitis. A sample of the effluent would need to be sent to the laboratory for culture and sensitivity in order to administer the correct antibiotic.

At 4:45 p.m., a nurse assesses a client with diabetes mellitus who is recovering from an abdominal hysterectomy 2 days ago. The nurse notes that the client is confused and diaphoretic. The nurse reviews the assessment data provided in the chart below: Capillary Blood Glucose Testing (AC/HS) At 0630: 95 At 1130: 70 At 1630: 47 Dietary Intake Breakfast: 10% eaten client states she is not hungry Lunch: 5% eaten client is nauseous; vomits once After reviewing the clients assessment data, which action is appropriate at this time? a. Assess the clients oxygen saturation level and administer oxygen. b. Reorient the client and apply a cool washcloth to the clients forehead. c. Administer dextrose 50% intravenously and reassess the client. d. Provide a glass of orange juice and encourage the client to eat dinner.

Administer dextrose 50% intravenously and reassess the client. The clients symptoms are related to hypoglycemia. Since the client has not been tolerating food, the nurse should administer dextrose intravenously. The clients oxygen level could be checked, but based on the information provided, this is not the priority. The client will not be reoriented until the glucose level rises.

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? Administration of oxygen via face mask Intravenous administration of 10% glucose Implementation of seizure precautions Administration of intravenous insulin

Administration of intravenous insulin The rapid, deep respiratory efforts of Kussmaul respirations are the bodys attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The client who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the client glucose would be contraindicated. The client does not require seizure precautions.

A nurse cares for a client who has excessive catecholamine release. Which assessment finding should the nurse correlate with this condition? a. Decreased blood pressure b. Increased pulse c. Decreased respiratory rate d. Increased urine output

B. Increased pulse Catecholamines are responsible for the fight-or-flight stress response.

A nurse plans care for an older adult who is admitted to the hospital for pneumonia. The client has no known drug allergies and no significant health history. Which action should the nurse include in this clients plan of care? a. Initiate Airborne Precautions. b. Offer fluids every hour or two. c. Place an indwelling urinary catheter. d. Palpate the clients thyroid gland.

B. Offer fluids every hour or two. A normal age-related endocrine change is decreased antidiuretic hormone (ADH) production. This results in a more diluted urine output, which can lead to dehydration. If no contraindications are known, the nurse should offer (or delegate) the client something to drink at least every 2 hours.

A nurse teaches an older adult with a decreased production of estrogen. Which statement should the nurse include in this clients teaching to decrease injury? a. Drink at least 2 liters of fluids each day. b. Walk around the neighborhood for daily exercise. c. Bathe your perineal area twice a day. d. You should check your blood glucose before meals.

B. Walk around the neighborhood for daily exercise. An older adult client with decreased production of estrogen is at risk for decreased bone density and fractures.

A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond? a. Glucose is the only fuel used by the body to produce the energy that it needs. b. Your brain needs a constant supply of glucose because it cannot store it. c. Without a minimum level of glucose, your body does not make red blood cells. d. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.

B. Your brain needs a constant supply of glucose because it cannot store it. Because the brain cannot synthesize or store significant amounts of glucose, a continuous supply from the bodys circulation is needed to meet the fuel demands of the central nervous system.

A nurse reviews the medication list of a client with a 20-year history of diabetes mellitus. The client holds up the bottle of prescribed duloxetine (Cymbalta) and states, My cousin has depression and is taking this drug. Do you think Im depressed? How should the nurse respond? Many people with long-term diabetes become depressed after a while. Its for peripheral neuropathy. Do you have burning pain in your feet or hands? This antidepressant also has anti-inflammatory properties for diabetic pain. No. Many medications can be used for several different disorders.

Its for peripheral neuropathy. Do you have burning pain in your feet or hands? Damage along nerves causes peripheral neuropathy and leads to burning pain along the nerves. Many drugs, including duloxetine (Cymbalta), can be used to treat peripheral neuropathy.

A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this clients teaching? When ill, avoid eating or drinking to reduce vomiting and diarrhea. Monitor your blood glucose levels at least every 4 hours while sick. If vomiting, do not use insulin or take your oral antidiabetic agent. Try to continue your prescribed exercise regimen even if you are sick.

Monitor your blood glucose levels at least every 4 hours while sick.

A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the clients polyuria? -Serum sodium: 163 mEq/L - Serum creatinine: 1.6 mg/dL - Presence of urine ketone bodies - Serum osmolarity: 375 mOsm/kg

Serum osmolarity: 375 mOsm/kg (elevated) Hyperglycemia causes hyperosmolarity of extracellular fluid. This leads to polyuria from an osmotic diuresis. The clients serum osmolarity is high. The clients sodium would be expected to be high owing to dehydration. Serum creatinine and urine ketone bodies are not related to the polyuria.

After teaching a client with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? I need to have an annual appointment even if my glucose levels are in good control. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick. I can still develop complications even though I do not have to take insulin at this time. If I have surgery or get very ill, I may have to receive insulin injections for a short

Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick. Clients with diabetes need to be seen at least annually to monitor for long-term complications, including visual changes, microalbuminuria, and lipid analysis. The client may develop complications and may need insulin in the future.

After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? The lower abdomen is the best location because it is closest to the pancreas. I can reach my thigh the best, so I will use the different areas of my thighs. By rotating the sites in one area, my chance of having a reaction is decreased. Changing injection sites from the thigh to the arm will change absorption rates

The lower abdomen is the best location because it is closest to the pancreas. The abdominal site has the fastest rate of absorption because of blood vessels in the area, not because of its proximity to the pancreas.

A 70-kg adult with chronic renal failure is on a 40-g protein diet. The client has a reduced glomerular filtration rate and is not undergoing dialysis. Which result would give the nurse the most concern? a. Albumin level of 2.5 g/dL b. Phosphorus level of 5 mg/dL c. Sodium level of 135 mmol/L d. Potassium level of 5.5 mmol/L

a. Albumin level of 2.5 g/dL Protein restriction is necessary with chronic renal failure due to the buildup of waste products from protein breakdown. The nurse would be concerned with the low albumin level since this indicates that the protein in the diet is not enough for the clients metabolic needs.

A nurse assesses clients who have endocrine disorders. Which assessment findings are paired correctly with the endocrine disorder? (Select all that apply.) a. Excessive thyroid-stimulating hormone Increased bone formation b. Excessive melanocyte-stimulating hormone Darkening of the skin c. Excessive parathyroid hormone Synthesis and release of corticosteroids d. Excessive antidiuretic hormone Increased urinary output e. Excessive adrenocorticotropic hormone Increased bone resorption

a. Excessive thyroid-stimulating hormone Increased bone formation b. Excessive melanocyte-stimulating hormone Darkening of the skin Thyroid-stimulating hormone targets thyroid tissue and stimulates the formation of bone. Melanocyte- stimulating hormone stimulates melanocytes and promotes pigmentation or the darkening of the skin.

A male client comes into the emergency department with a serum creatinine of 2.2 mg/dL and a blood urea nitrogen (BUN) of 24 mL/dL. What question should the nurse ask first when taking this clients history? a. Have you been taking any aspirin, ibuprofen, or naproxen recently? b. Do you have anyone in your family with renal failure? c. Have you had a diet that is low in protein recently? d. Has a relative had a kidney transplant lately?

a. Have you been taking any aspirin, ibuprofen, or naproxen recently? There are some medications that are nephrotoxic, such as the nonsteroidal anti-inflammatory drugs ibuprofen, aspirin, and naproxen. This would be a good question to initially ask the client since both the serum creatinine and BUN are elevated, indicating some renal problems.

A nurse assesses a client who is prescribed a medication that stimulates beta1 receptors. Which assessment finding should alert the nurse to urgently contact the health care provider? a. Heart rate of 50 beats/min b. Respiratory rate of 18 breaths/min c. Oxygenation saturation of 92% d. Blood pressure of 144/69 mm Hg

a. Heart rate of 50 beats/min Stimulation of beta1 receptor sites in the heart has positive chronotropic and inotropic actions. The nurse expects an increase in heart rate and increased cardiac output. The client with a heart rate of 50 beats/min would be cause for concern because this would indicate that the client was not responding to the medication. The other vital signs are within normal limits and do not indicate a negative response to the medication

4. A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.) a. How frequently do you drink alcohol? b. Have you ever had sex with a man? c. Do you have a family history of cancer? d. Have you ever worked as a plumber? e. Were you previously incarcerated?

a. How frequently do you drink alcohol? b. Have you ever had sex with a man? e. Were you previously incarcerated?

A client is assessed by the nurse after a hemodialysis session. The nurse notes bleeding from the clients nose and around the intravenous catheter. What action by the nurse is the priority? a. Hold pressure over the clients nose for 10 minutes. b. Take the clients pulse, blood pressure, and temperature. c. Assess for a bruit or thrill over the arteriovenous fistula. d. Prepare protamine sulfate for administration.

d. Prepare protamine sulfate for administration. Heparin is used with hemodialysis treatments. The bleeding alerts the nurse that too much anticoagulant is in the clients system and protamine sulfate should be administered. Pressure, taking vital signs, and assessing for a bruit or thrill are not as important as medication administration.