Elevate 4
What is priority for the client experiencing hyperparathyroid crisis? 1. Support for airway and breathing. 2. Continuous cardiac monitoring for arrhythmias. 3. Provide safety precautions. 4. Prepare for emergency tracheostomy.
1. Correct: Always remember ABC, if it is relevant, and it is with hyperparathyroid crisis. 2. Incorrect: Circulation is important. This priority comes after attention has been directed toward airway and breathing. What good would come of circulating deoxygenated blood, and how long can the heart muscle last without oxygen? Always remember ABC when prioritizing in emergency situations. 3. Incorrect: Muscle weakness, thus risk for falls is a concern, but airway takes priority! 4. Incorrect: Trach would be more likely with hypoparathyroidism. Remember, in hypoparathyroidism, the client would have rigid and tight muscles which would cause laryngospasms.
What should a community health nurse include when planning a presentation on prevention and early detection of colon cancer? 1. Maintain a diet high in fruits, vegetables, and whole grains. 2. Exercise regularly. 3. Regular screening should begin at age 30. 4. Yearly fecal occult blood test beginning at age 50. 5. Flexible esophagogastroduodenoscopy every 5 years.
1., 2., & 4. Correct: A diet high in vegetables, fruits, and whole grains have been linked with a decreased risk of colorectal cancer, whereas, a diet high in red meats, processed meats, and frying can increase risk of colorectal cancer. There is a greater risk of developing colorectal cancer in individuals who live a sedentary life style. The fecal occult blood test detects blood in the stool through a chemical reaction. This test is done yearly. 3. Incorrect: If there is no identified risk factors (other than age), regular screening should begin at age 50. 5. Incorrect: A flexible esophagogastroduodenoscopy is not a recommended procedure for the early detection of cancer of the colon.
What should the nurse include in a discharge plan for a client diagnosed with lymphoma who will be receiving outpatient treatment? 1. Avoid uncooked meats, seafood or eggs and unwashed fruits and vegetables. 2. Take bleeding precautions. 3. Do not take influenza or pneumonia vaccine during treatment. 4. Avoid individuals with infections. 5. Emphasize importance of frequent oral hygiene with an alcohol based mouthwash.
1., 2., & 4. Correct: The client with lymphoma is susceptible to infection and should eat foods low in bacteria. The client should avoid uncooked meats, seafood or eggs and unwashed fruits and vegetables as the bacteria count will be higher than desired. Instruct client and family about bleeding precautions and management of active bleeding due to thrombocytopenia. They should be advised to avoid activities that place them at risk for injury or bleeding (including excessive straining). This client is at risk for infection due to low white count, so the client should avoid individuals who are ill. 3. Incorrect: Encourage clients to maintain current immunizations for influenza and pneumonia. They are more susceptible to infection. Cancer and cancer treatment can weaken the immune system, which puts them at higher risk of serious problems if they get the flu or pneumonia. Only live vaccines (MMR, varicella, oral polio) are contraindicated in clients receiving chemotherapy. 5. Incorrect: This client is at risk for bleeding and infection due to low platelet and white cell counts. The client needs frequent oral care with a soft toothbrush and alcohol free mouthwash. Alcohol-based mouthwashes can dry out the gum and increase bleeding.
The nurse is providing foot care to the client who has diabetes. What should the nurse include in the teaching? 1. Inspect the feet daily for abrasions or pressure areas. 2. Check water temperature with the hands before getting into tub. 3. Do not use heating pads on the feet or lower legs. 4. Thoroughly dry the feet, especially between the toes. 5. Cut toenails rather than file them. 6. Cut nails in a rounded fashion
1., 2., 3. & 4. Correct: The feet should be inspected daily. Small tears or abrasions can occur without the client's awareness due to decreased sensation in the feet. The client may be burned by getting into water that is too hot due to decreased sensation in the feet. There is less chance of decreased sensation in the hands. Heating pads may burn the client's feet. It is better to apply blankets for warmth. Drying the feet and between the toes will prevent skin breakdown. 5. Incorrect: Filing is safer, as it is not likely to result in cutting or irritating the skin around the nail. A cut on the lower extremity can result in an infection. Clients should not cut their nails. Filing is safer. 6. Incorrect: The nails should be filed straight across. Filing into a round shape may result in an ingrown toenail, which may lead to infection. Skin breaks on the lower extremity can lead to infection.
What discharge instructions should the nurse include for a client following a transsphenoidal hypophysectomy? 1. Sleep with head of bed at 35 degrees. 2. Notify the primary healthcare provider for an increased urinary output. 3. Brush the teeth three times a day followed by rinsing with a commercial mouthwash. 4. Nasal packing will need to be removed in 48 hours. 5. Use a humidifier in the room.
1.,2., 5. Correct. Sleeping with the head of the bed elevated will promote drainage of cerebrospinal fluid. An increased UOP could indicate diabetes insipidus, an adverse reaction to this surgical procedure. Humidified air prevents drying of nasal passages. 3. Incorrect. Because the incision for this surgery is just above the gumline, the client should not brush the front teeth. Oral care should be performed with a sponge until the incision heals. 4. Incorrect. There is no nasal packing. The incision is located just above the gumline of the upper teeth.
A nurse is caring for a client who is diagnosed with diabetic ketoacidosis (DKA). Which primary healthcare provider prescription is appropriate during the first 24 hours of treatment for this client? 1. 0.45% saline solution (NaCl) at 50 mL/hr 2. 3% saline solution (NaCl) at 125 mL/hr 3. 0.9% saline solution (NaCl) at 1,000 mL/hr times 2 4. Dextrose 5% in lactated Ringer's solution at 150 mL/hr
3. Correct: 0.9% saline solution should be infused at a rate of at 1,000 mL/hr times 2, up to a total of 10 L in the first 24 hours of treatment. This client will be in a fluid volume deficit or shock and fluid replacement is essential. 1. Incorrect. 0.45% saline would not be administered at 50 mL/hr because the first goal of fluid therapy in DKA is to restore volume in a severely volume depleted client, thus we need normal saline at a faster rate to replace fluid volume. 2. Incorrect. 3% saline solution would be contraindicated in this client because it is a hypertonic solution that would worsen the client's dehydration. 4. Incorrect. Dextrose 5% in lactated Ringer's solution at 150 mL/hr is inappropriate because the blood sugar is too high for infusion of a dextrose containing solution.
A nurse is conducting an initial admission history on a client who is reporting bone pain secondary to cancer with metastasis to the bone. What does the nurse determine is the most important information to gather during this initial screening? 1. The physical assessment of the client 2. The hemoglobin and hematocrit levels 3. The amount of pain medication the client is receiving 4. The client's description of the pain
4. Correct: The most important information to gather during the initial screening is the client's perception and description of the pain. Pain is subjective, based on the client's perception. This is also the primary complaint of the client upon admission. 1. Incorrect: The question is asking about the client's pain. The physical assessment is important but does not address the client's perception of their own pain. 2. Incorrect: RBCs are produced in the bone marrow. The H&H might be affected but will not be the cause of the pain and assessed later with admission lab and diagnostics. 3. Incorrect: The amount of pain medication is important, but is not the most important information to gather from a client who is reporting pain, particularly with cancer and metastatic bone pain.
What is the nursing priority for the client experiencing hyperparathyroidism? 1. Continuous cardiac monitoring. 2. Initiate fall precautions. 3. Administer IV normal saline. 4. Begin preparations for emergency parathyroidectomy.
1. Correct: To much calcium equals sedation. Life threatening complications such as airway obstruction and cardiact arrest may occur from severely high levels of calcium. 2. Incorrect: Preventing injury is important because of bone density loss and risk of fractures. But it is not the priority. Done after maintaining airway and circulation. 3. Incorrect: IV normal saline in large volumes is done to promote calcium excretion, but it is not the priority over airway and circulation. 4. Incorrect: Surgery is indicated "when medically feasible". Cardiac monitoring is the priority at this time.
A client has been receiving 5-fluorouracil treatments for colon cancer and is admitted with weakness, fatigue, thrombocytopenia and low grade fever. Which actions would be appropriate for this client? 1. Dedicated supplies in room 2. Semi-private room 3. Liquid diet 4. Limit visitors 5. Nasogastric tube placement
1., & 4. Correct. This client is at risk for infection and bleeding. Keeping dedicated supplies in room will decrease the risk of infection. Limiting visitors will decrease risk of infection. 2. Incorrect. This client needs a private room because the client is immunocompromised. 3. Incorrect. Unless contraindicated, the client would be prescribed a high-calorie, high-protein diet. 5. Incorrect: To minimize the risk of bleeding, restrict the placement of nasogastric tubes, rectal tubes, and suctioning equipment.
Which interventions should a nurse discuss with a client for primary prevention of skin cancer from exposure to ultraviolet light? 1. Use sunscreen when outdoors. 2. Stay in the shade when outdoors. 3. Wear wide brimmed hats when outdoors. 4. Examine skin every 3 months for changes. 5. Have an annual skin assessment by a dermatologist.
1., 2. & 3. Correct: Using sunscreen, staying in shaded areas, and wearing wide brimmed hats are effective interventions to prevent skin cancer. 4. Incorrect: Examine your whole body monthly for possible changes that may be precancerous or cancerous lesions. Early detection is considered secondary prevention. 5. Incorrect: Assessment by a dermatologist is not a primary prevention strategy. Early diagnosis is considered secondary prevention.
What signs and symptoms of ovarian cancer should a nurse include when educating women? 1. GI disturbances 2. Menstrual changes 3. Malnutrition 4. Increasing abdominal girth 5. Pain radiating down the legs
1., 2., & 4. Correct: Signs and symptoms of ovarian cancer include irregular menses, increasing premenstrual tension, menorrhagia with breast tenderness, early menopause, abdominal discomfort, dyspepsia, pelvic pressure and urinary frequency. Indigestion, flatulence, and fullness after a light meal, and increasing abdominal girth are significant symptoms. 3. Incorrect: Malnutrition is a complication of advanced metastatic cancer. 5. Incorrect: Pain will be in the abdomen and pelvis, and does not radiate down the legs.
A nurse is planning discharge education for a client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Which instructions should the nurse include when teaching this client? 1. Limit fluid intake. 2. Report muscle cramping. 3. Measure intake and output. 4. Perform mouth care once a day. 5. Report weight gain of 2 pounds (0.9 kg) over 24 hours.
1., 2., 3. & 5. Correct: The nurse should advise the client diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH) to limit fluid intake. In SIADH, excessive amounts of water are reabsorbed by the kidneys, creating potentially disastrous dilutional hyponatremia. Water must be restricted to prevent water intoxication. The nurse should advise the client diagnosed SIADH to report muscle cramping. Muscle cramping should be reported immediately to the primary healthcare provider because this sign could indicate hyponatremia, which can lead to seizures or coma. The nurse should advise the client diagnosed with SIADH to measure intake and output. Intake and output should be monitored carefully to assess the amount of fluid restriction needed. Weight gain of 2 pounds (0.9 kg) or more should be reported to the primary healthcare provider because this is an indication of fluid retention and increases the client's risk for fluid volume excess. 4. Incorrect: The nurse should teach the client to rinse the mouth frequently to keep mucous membranes moist during fluid restriction, not just once a day.
A client with a severe cough is suspected of having lung cancer. When preparing the client for testing to confirm a diagnosis of cancer, which tests should a nurse anticipate? 1. Chest x-ray 2. Arterial blood gas 3. Bronchoscopy 4. Computed tomography (CT) 5. Pulmonary function test
1., 3., & 4. Correct: Chest x-ray, bronchoscopy, and CT scan are evidenced-based tests used in the diagnosis of lung cancer due to the efficacy of the tests. 2. Incorrect: Arterial blood gas measures the quantity of oxygen in the blood and acid-base status. 5. Incorrect: Pulmonary function test is used to diagnose obstructive lung diseases, such as emphysema.
A client with acute pancreatitis is prescribed total parenteral nutrition (TPN), methylprednisolone, and sliding scale insulin. What is the rationale for the insulin prescribed? 1. Impaired endocrine function of the pancreas 2. Inability of the liver to convert glucose 3. Steroid therapy side effects 4. Dextrose concentration of TPN 5. Re-establish serum potassium level
1., 3., & 4. Correct: Really what we are saying here is why would the client be on insulin? Well, the pancreas is damaged and so the endocrine function of the pancreas is impaired. We know that hyperglycemia or pseudo diabetes is a side effect of steroid therapy and TPN is high in glucose and may require additional insulin. These are the three rationales for why they might need insulin. 2. Incorrect: If the liver can't convert glucose that will decrease the insulin need so that one is false. 5. Incorrect: Is not related at all. The NCLEX people want you to say,"I remember something about potassium and glucose, but I am not sure what. Don't fall for that, this is false. The rationale for the Insulin order is not to re-establish potassium in this question.
A client with type 2 diabetes, who is noncompliant, has a HbA1c of 8%. The finger stick blood sugar is 218 mg/dL (12.1 mmol/L) at 0900. The current medications prescribed are metformin and exenatide. Based on this data, what teaching should the nurse reinforce? 1. Nutritional counseling to help improve diet compliance 2. HbA1c measures glycemia control over a period of 1 month 3. Blood glucose testing 4. Vigorous exercise plan to improve glucose control 5. Without glycemic control, eye complications can occur
1., 3., & 5. Correct: The goal of therapy is to have a HbA1c <7.0% Nutritional teaching to promote diet compliance should be tried first because this clients HbA1c is 8% and blood sugar is 218 mg/dL (12.1 mmol/L). Reinforce need to monitor glucose levels several times a day, before meals and at bedtime. Have client keep results in a log. Eye complications include glaucoma, cataracts, retinopathy, blindness. 2. Incorrect: HbA1c measures glycemic control over a period of 3 months. 4. Incorrect: Physical activity under the supervision of the primary healthcare provider is appropriate teaching. Vigorous exercise is not key to improving blood sugar. Exercise does not have to be intense. A normal exercise plan is recommended based on the client's ability.
A client diagnosed with cancer has been losing weight. What should the nurse teach the client regarding methods for improving nutritional needs to maintain weight? 1. Add butter to foods. 2. Cup of cubed beef broth. 3. Add powdered creamer to milkshake. 4. Use biscuits to make sandwiches. 5. Fish sauted in olive oil. 6. Put honey on top of hot cereal.
1., 3., 4., & 6. Correct: Butter added to foods adds calories. This client needs more calories and more protein. Spread peanut butter or other nut butters, which contain protein and healthy fats, on toast, bread, apple or banana slices, crackers or celery. Use croissants or biscuits to make sandwiches which provides more calories. Add powered creamer or dry milk powder to hot cocoa, milkshakes, hot cereal, gravy, sauces, meatloaf, cream soups, or puddings to add more calories. Top hot cereal with brown sugar, honey, dried fruit, cream or nut butter. 2. Incorrect: One cube of beef broth is 11 calories. Supplementing the diet with beef broth would not add significant calories. 5. Incorrect: Although cooked in olive oil, fish is low in calories.
A nurse is reviewing serum laboratory data for four clients. Which client would require the most immediate assessment? 1. Client A 2. Client B 3. Client C 4. Client D
2. Correct: An excess of thyroid hormone is the most life-threatening of the findings listed due to its effects on the cardiovascular system of hypertension and tachycardia. The client should be assessed for impending thyroid storm. 1. Incorrect: An elevated TSH level occurs in hypothyroidism. TSH is needed to ensure proper synthesis and secretion of the thyroid hormones which are essential for life. Not life-threatening. 3. Incorrect: An elevated growth hormone produces acromegaly with resulting bone and soft tissue deformities and enlarged viscera. But this is not life threatening. 4. Incorrect: Though the glucose level is elevated, a level of 150 mg/dL (8.3 mmol/L) does not require immediate assessment or intervention.
A 13 year old found unresponsive in the park is brought into the emergency department (ED). The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and attempts to call them have been unsuccessful. What action should the nurse take? 1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs for administration of normal saline. 3. Give Glucagon IM and then wait for the arrival of a parent to consent to further treatment. 4. Notify the pirmary healthcare provider.
2. Correct: Consent for a minor is not needed in the event of an emergency. Begin treatment for Diabetic Ketoacidosis (DKA). 1. Incorrect: Consent for a minor is not needed in the event of an emergency. The social worker does not give consent in this situation. 3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not needed. Emergency treatment can be provided without parental consent for a minor. 4, Incorrect: The primary healthcare provider cannot give consent or treatment in the ED. The ED physician and nurses can provide treatment in an emergency.
A client's absolute neutrophil count (ANC) is 750/mm3. Which measure should the nurse take to protect the client? 1. Prohibit the client from shaving. 2. Instruct the client to wear a mask when leaving the hospital room. 3. Remove fresh flowers and plants from the client's room. 4. Ask visitors to perform hand hygiene before entering the client's room. 5. Instruct client to avoid vigorous flossing of teeth.
2., 3. & 4. Correct: Normal ANC is 1500-8000/mm3. If a client's ANC is less than 1000/mm3, the client is at risk for infection. Instructing the client to wear a mask outside of the hospital room protects the client from infection. The soil in fresh flowers and plants can carry bacteria and fungi, which can cause infection. Performing hand hygiene is the best way to prevent the spread of infection. 1. Incorrect: Not allowing the client to shave or vigorous flossing of teeth would be an appropriate intervention for someone with a low platelet count. This client has a low white cell count. 5. Incorrect: Not allowing the client to shave or vigorous flossing of teeth would be an appropriate intervention for someone with a low platelet count.
A client has been prescribed levothyroxine sodium. What should the nurse teach the client about this medication? 1. Treatment will last for one year. 2. Notify the primary healthcare provider of chest pain. 3. Take medication ½ hour before breakfast. 4. Take calcium supplements 4 hours after taking levothyroxine. 5. Improvement of symptoms will occur within 2 days.
2., 3. & 4. Correct: YES! Get medical help immediately if the side effect of chest pain occurs. It could be an MI. It is preferable to take medication on an empty stomach, ½ - 1 hr before breakfast. Levothyroxine should not be administered within 4 hours of calcium supplements. 1. Incorrect: No, this medication is will need to be taken for the rest of the client's life. 5. Incorrect: It may take several weeks for symptoms to improve.
What medications would the nurse anticipate for the treatment of hyperthyroidism? 1. Levothyroxine 2. Methimazole 3. Propranolol 4. Iodine compounds 5. Calcitonin
2., 3., & 4. Correct: Methimazole is correct because it decreases the production of thyroid hormones. It is an antithyroid drug and it is used to "stun" the thyroid pre-operatively. It makes the thyroid "freak out" and stop producing hormones temporarily. Propanolol is correct because it is a beta blocker and beta blockers decrease the heart rate and decrease anxiety. Why is this important? Because the heart rate and anxiety are going to be increased in the hyperthyroid client. Iodine compounds like Lugol's solution® are correct because these decrease the size and vascularity of the thyroid gland. Do you think this might be important pre-operatively?YES, to decrease the likelihood of bleeding/hemorrhage. And we also, just learned that pharmacologic doses of iodine will also do what? That's right, large doses will decrease thyroid hormone production for a few weeks. So that's two reasons we might use an Iodine compound for Hyperthyroidism. 1. Incorrect: We are not going to give levothyroxine, that's just going to make the problem worse! Because what is levothyroxine? That's right it's the synthetic form of T4. 5. Incorrect: What about calcitonin? It is a thyroid hormone too! They don't need more! They are hyperthyroid! So False.
The nurse is caring for a client with Addison's disease that is taking fludrocortisone 0.1mg/day. What assessment data by the nurse would suggest that the client's dose is too high? 1. Weight loss of 2 lbs (0.907 kg)/24 hours 2. Elevated serum sodium level 3. Bilateral pedal edema 4. Crackles in the lung fields bilaterally 5. Elevated blood pressure
2., 3., 4., & 5. Correct: Now, remember that with Addison's disease the client does not have enough steroids, so we have to ADD steroids. All of these options indicate the client is holding onto fluid, and we would expect the client to hold onto fluid when their steroid dose is too high. 1. Incorrect: We would expect weight gain with this client, and what is the amount of weight gain we worry about? That's right, anything over 2-3 lbs (0.907 - 1.360 kg) in 24 hours.
Which statements made by a client diagnosed with Addison's disease indicates to the nurse that the client understands fludrocortisone therapy? 1. "Taking my medicine at night will help me sleep." 2. "It is important to wear a medical alert bracelet all of the time." 3. "I will limit my sodium intake to 200 mg per day." 4. "My medication dose will change based on my daily weight." 5. "I may need more medication if I feel weak or dizzy."
2., 4., & 5. Correct: Medical alert bracelet is an excellent way of informing healthcare providers of a life threatening condition if the client is unable to verbalize that information. Steroid therapy is adjusted according to the client's weight and signs of fluid volume status. Signs of being undermedicated include weakness, fatigue, and dizziness. The client will need to report these symptoms, so more medication can be given to the client. 1. Incorrect: Steroids can cause insomnia so the client does not need to take the medication prior to going to bed. 3. Incorrect: This client needs a high sodium diet as they are losing sodium and retaining potassium.
What is the priority electrolyte imbalance for the nurse to monitor when caring for a client post op thyroidectomy? 1. Hypercalcemia 2. Hyperkalemia 3. Hypocalcemia 4. Hypomagnesemia
3. Correct: Why is hypocalcemia the correct answer? The complication from removal of the thyroid is possible injury or removal of parathyroid glands. This produces a disturbance in calcium levels. The calcium levels fall resulting in hypocalcemia. 1. Incorrect: No, the calcium is not elevated. With possible removal of the parathyroid glands during thyroidectomy the calcium will decrease. 2. Incorrect: Potassium is not the priority electrolyte to monitor post thyroidectomy. 4. Incorrect: No, magnesium is not the priority electrolyte to monitor post thyroidectomy.
Which risk factor should the nurse include when planning to educate a group of women about breast cancer? 1. Menopause before the age of 50 2. Drinking one glass of wine daily 3. Multiparity 4. Early menarche
4. Correct: Early menarche before age 12 is a known risk factor for breast cancer. The increased risk of breast cancer linked to a younger age at first period is likely due, at least in part, to the amount of estrogen a woman is exposed to in her life. A higher lifetime exposure to estrogen is linked to an increase in breast cancer risk. The earlier a woman starts having periods, the longer her breast tissue is exposed to estrogens released during the menstrual cycle and the greater her lifetime exposure to estrogen. 1. Incorrect: Studies show women who go through menopause after age 50 have increased risk of breast cancer. The risk for breast cancer increases as time period between menarche and menopause increases.2. Incorrect: Small increase in risk with moderate alcohol consumption, not one glass of wine daily. Drinking low to moderate amounts of alcohol, however, may lower the risks of heart disease, high blood pressure and death. But, drinking more than one drink per day (for women) and more than two drinks per day (for men) has no health benefits and many serious health risks, including breast cancer. Alcohol can change the way a woman's body metabolizes estrogen (how estrogen works in the body). This can cause blood estrogen levels to rise. Estrogen levels are higher in women who drink alcohol than in non-drinkers. These higher estrogen levels may in turn, increase the risk of breast cancer. 3. Incorrect: Nulliparity (no pregnancies) is a known risk factor for breast cancer. Factors that increase the number of menstrual cycles also increase the risk of breast cancer, probably due to increased endogenous estrogen exposure.