ex 2

the client with liver failure is ordered to receive lactulose 30grams four times a day. available is lactulose 10grams/15ml how many ml will the client receive in each dose whole number?

45ml

the nurse instructs a patient with low levels of circulating thyroid hormone to increase foods in the diet containing which of the following? a. Iodine b. Calcium c.Protein d. Vitamin B

a. Iodine

which of the following screening tools is important for the nurse to discuss with the client at risk for problems with mobility? a. bone density scan b.MRI c. Angiography d.Endoscopy

a. bone density scan the bone density scan is a screening tool to predict osteoporosis

the nurse is caring for a client with a history of hyperthyroidism the day after an appendectomy. during assessment the nurse observes the client has tremors, agitation and is complaining of a racing heart. Vital signs are: T: 105.3deg f , P:120, R:24, BP: 150/70. the nurse's first priority a. ensure adequate airway b. arrange for 12 lead ECG c.adminstier Synthroid po d. initiate a large bore IV

a. ensure adequate airway goal of therapy is to reduce circulating thyroid hormones. supportive therapy includes managing airway, reducing fever, replacing fluid and eliminating or managing the initiating stressors.

while assessing a client who is taking a rosiglitazone (Avandia) the nurse should assess for which of the following complications? a. heart failure and liver toxicity b. diarrhea and flatulence c. nausea and vomiting d. headache and flushing

a. heart failure and liver toxicity Thiazolidinediones may increase the risk for heart failure and liver toxicity. Sulfonylureas may interact with alcohol and cause headache, flushing, and nausea.

the nurse is educating a client with cirrhosis about portal hypertension. which of the following symptoms should the nurse discuss with the client? a. hemorrhoids b. hypothermia c. muscle wasting d. bleeding gums

a. hemorrhoids

the nurse is evaluating the client with Addison's disease for adrenal insufficiency. which of the following symptoms does the nurse anticipate select all that apply? a. hypotenison b. hyperglycemia c.hyperkalemia d.hyperthermia e.hypoxia

a. hypotension c. hyperkalemia

a nurse is caring for a 7 year old client newly diagnosed with type 1 diabetes. which statement indicates the family has a good understanding of the importance of glucose control? a. i will go out and get a special book that we can keep track of his blood glucose numbers and food intake, just in case the meter ever fails b. this is so much information and very overwhelming for children especially we should manage the disease and medications c. with this new diagnosis i will need to contact all of the coaches and let them know he can't participate in sports any longer

a. i will go out and get a special book that we can keep track of his blood glucose numbers and food intake, just in case the meter ever fails

the school nurse is working with the PTA to teach parents about childhood obesity. which of the following are risk factors the nurse should include when talking with parents? select all that apply? a. if the child is being bullied at school b.packing high sugar drinks and high carbohydrate foods in a child's lunch c.increase the amount of screen time each day, with a reduction of physical activity d.riding the bus to school e.low socioeconomical status

a. if the child is being bullied at school b.packing high sugar drinks and high carbohydrate foods in a child's lunch c.increase the amount of screen time each day, with a reduction of physical activity e.low socioeconomical status

the client is ordered propanolol Inderal 1mg IV for thyroid storm. the client asks the nurse why. this medication is being given. the nurses best response is: a. it will improve some of the symptoms caused by your nervous system b. it will help to improve your appetite c. it will reduce the headache you may be experiencing d. it will lower your heart rate. without lowering your blood pressure

a. it will improve some of the symptoms caused by your nervous system B-adrenergic blockers are used for symptomatic relief of thyrotoxicosis they block the effects of the sympathetic nervous system: decreasing the HR nervousness, irritability, and tremors.

the nurse is conducting a class in a senior center on osteoarthritis. which of the following are goals for management of osteoarthrits? select all that apply a. mild exercise b. avoid weight bearing exercise c. maintain proper joint alignment d. adequate rest e. weight reduction

a. mild exercise c. maintain proper joint alignment d. adequate rest e. weight reduction

a client with cirrhosis has been receiving Lactulose. how does nurse determine the medication has been effective. a. oriented to person, place and time b. frequent loose brown stools c. white sclera d.urine output > 30ml/hr

a. oriented to person, place and time Lactulose is a medication given to reduce serum ammonia levels and improvement in mentation is a sign it has been effective

the nurse is caring for a client with a leg cast for a fractured femur. the client reports increased pain that is unrelieved by analgesic medication. which of the following actions should the nurse take first? a. perform a neurovascular assessment b. instruct client on the use of relaxation techniques c. call hcp for an additional dose of pain medication d.obtain vital signs

a. perform a neurovascular assessment

The nurse is caring for a school- aged client with a deficiency in growth hormone. which of the following assessment findings does the nurse anticipate? a. smaller stature than children of the same age b. intolerance to temperature changes c. excessive thirst d. abnormally large for age and gender

a. smaller stature than children of the same age a deficiency in growth hormone will result in children that are smaller in size and stature than children of the same age and gender

the nurse is assessing the client with parkinsons disease. which of the following are safety concerns for this client? select all that apply a. stooped posture b.toppling back when bumped or standing c.shuffling parkinsonian gait d. pill rolling motion in fingers and thumb

a. stooped posture b.toppling back when bumped or standing c.shuffling parkinsonian gait

the nurse is assessing the client walking with a cane. which of the following indicates the client requires further teaching regarding ambulating with a cane? a. the height of the cane is too low for the client and should be adjusted b. the cane should be on the opposite side c. the client should grip the top of the cane for support, rather than the side d.the client should only use a cane with a quad base of support

a. the height of the cane is too low for the client and should be adjusted the cane should be at an appropriate height relative to the clients height. this cane is too low for the client

the caregiver for a client that takes Levodopa tells the nurse they have noticed that the client movements seem to be much slower in the late afternoon than earlier in the day. which of the following is appropriate response from the nurse? a. the medication may be wearing off, which makes the results less predictable b. make sure to get a long nap after lunch c. we will need to let the healthcare provider know about this right away d. try the medication with a meal high in protein

a. the medication may be wearing off, which makes the results less predictable

the spouse of a client with parkinsons disease is speaking to the nurse about concerns that the client seems sad and isn't participating in family activities any more. which of the following responses by the nurse is appropriate at this time? a. this may be caused by the overwhelming feeling of not being able to cope b. i would advise you to call the healthcare provider about this immediately c. nothing to worry about it, it is just part of the disease progression d. it is associated with obstructive sleep apnea

a. this may be caused by the overwhelming feeling of not being able to cope there are emotional changes associated with parkinsons disease this includes depression, panic attacks, fear and anxiety. client may experience an inability to cope resulting in social withdrawal and apathy

the nurse received report on a group of clients on an orthopedic floor. which client should the nurse see first? a. tibia fracture, casted. complaining of numbness, tingling, and swelling toes on affected side b. humerus fracture waiting on repair, with pain and swelling in arm c. femur fracture with skeletal traction with warmth and redness at pin sites d. post open reduction internal fixation of a right hip complaining of pain at surgical site

a. tibia fracture, casted. complaining of numbness, tingling, and swelling toes on affected side

the nurse is admitting a client after surgery for a posterior pituitary tumor. which of the following assessment findings requires immediate intervention by the nurse? a. urine output of 700ml over one hour b. increased thirst c. dry, brittle nails d. blood glucose 110mg /dl

a. urine output of 700ml over one hour the client with a posterior pituitary tumor needs to be monitored for diabetes insipidus one of the symptoms is excessive urine output

when a client is taking anticholinergic such as benztropine (Cogentin) as part of the treatment for parkinsons disease, the nurse should include which information in the teaching plan? a. use artificial saliva, sugarless gum, or hard candy to counteract dry mouth. b. discontinue the medication if adverse effects occur c. take the medication on an empty stomach to enhance absorption d. minimize the amount of fluid taken while on this drug

a. use artificial saliva, sugarless gum, or hard candy to counteract dry mouth. dry mouth can be managed with artificial saliva through drops or gum frequent mouth care, forced fluids, and sucking on sugar free hard candy

the nurse is caring for an elderly client with osteoporosis. which of the following findings is a safety concern for the client with osteoporosis? a. participating in smoking cessation programs b. ambulating with an unsteady gait c. residing in an assisted living facility d. maintaining a steady weight

b. ambulating with an unsteady gait the client with osteoporosis is at an increase risk for falls if they have an unsteady gait when ambulating

the nurse and the UAP are performing morning care on the client after a total hip replacement. the nurse should intervene when the UAP does which of the following? a. place the disposable pad on the bedding under the dressing b. asks the client pull the knee to the chest for repositioning c. keeps the abduction pillow in place for repositioning d. asks the client to wash her face

b. asks the client pull the knee to the chest for repositioning the concern after a total hip replacement is dislodgment of the prosthesis. thus the client should not pull the knee to the chest

the nurse observes a client using crutches to walk. which statement by the client indicates additional teaching by the nurse is needed? a. i should stand up straight and never hunched over when using crutches b. i should consider wearing shoes with a low heel and maybe even ones that won't come untied such as velcro shoes or flip flops c. i will always start in the tripod position for support and balance d. i need to make sure that the crutches fit right and i am not bearing all of my weight on my armpits

b. i should consider wearing shoes with a low heel and maybe even ones that won't come untied such as velcro shoes or flip flops

a nurse is supervising a newly licensed nurse providing discharge instructions for a client with a broken bone. which of the following statements demonstrates the nurse has a good understanding of the healing process after a broken bone? a. we will be assessing for malunion, indicating the fracture has healed b. it will take about 6-8weeks for the fracture to repair c. if the bone doesn't heal properly, we can rebreak it and then it will heal d. because the bone is a continuous structure, healing should be simple

b. it will take about 6-8weeks for the fracture to repair when a fracture occurs the bone healing goes through three stages. first inflammatory phase. followed by reparative stage last 6-8weeks

a client with diabetes mellitus, type 2 comes to the clinic and tells the nurse he has been experiencing dry skin on his lower extremities and they are warm to touch. Prior to the assessment, the nurse is concerned the patient may be experiencing which complication from T2D? a. neuropathy b. peripheral vascular disease c. microvascular complications d. limited range of motion

b. peripheral vascular disease PVD can occur in both types of diabetes.

for a client with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? a. palpating the abdomen for distention b. providing oral hygiene after a meal c. assisting the patient to choose the diet d. assessing the client for jaundice

b. providing oral hygiene after a meal providing oral hygiene is within the scope of UAP. assessments and assisting patients to choose therapeutic diets are nursing actions that require higher level nursing education and scope of practice and would be delegated to licensed practical/vocational nurses

the nurse finds the client on floor. the client reports that they fell when walking to the bathroom. the client is complaining of pain in the right hip and groin. which additional assessment finding is consistent with a hip fracture? a. stiffness when flexing the left hip b. the right leg is outwardly rotated c.the client feels lightheaded d.the client was incontinent of urine

b. the right leg is outwardly rotated the clinical manifestations of a hip fracture include pain in the hip and groin. the affected leg may appear shorter than the other

which of the following is important for the nurse to include in the discharge plan for a client with osteoarthritis? a. apply heat for 1 hour at a time b.perform range of motion exercises daily c. take extra doses of NSAIDS when needed d. avoid weight loss

b.perform range of motion exercises daily

the nurse is caring for several clients with diabetes. which of the following assessment findings should the nurse intervene with first? a. blood glucose level 180mg/dL b. Heart rate 60 beats per minute c. Potassium level 3.0mEq d. Temperature 100.1 deg F

c. Potassium level 3.0mEq the most life threatening assessment finding is potassium of 3.0mEq

the hcp ordered a hemoglobin A1C test for a client with diabetes. the nurse recognizes that the hcp ordered this test in order to: a. diagnose the client with diabetes b. determine if the client is experiencing hypoglycemia c. assess the clients glucose control over the last 90 days d. assess for early onset of neuropathy

c. assess the clients glucose control over the last 90 days Hemoglobin A1C is a test used to determine the average blood glucose level over approximately to the previous 2-3months

the nurse is teaching a class on weight management to a group of clients. which of the following is important for the nurse to include in the presentation? a. cut calories to 400 calories per day until there is a 10 pound weight loss b. exercise no less than 60 minutes every day c. behavior modification is a crucial component of successful weight loss d. any fluid intake is fine, no matter what type of fluid

c. behavior modification is a crucial component of successful weight loss behavior modification includes logging food intake and activity each day is crucial for successful weight loss.

a client is admitted to the emergency room with a change in mental status. which of the following assessments is a priority for the nurse to perform? a. auscultation of abnormal heart sounds b. capillary refill time c. finger stick blood glucose d. pupil reaction to light

c. finger stick blood glucose change in the clients mentation can be a sign of stroke, cardiac dysfunction, or hypo or hyperglycemia. hyperglycemia mimics the effects of a stroke. finger stick for blood glucose should be a priority assessment

the nurse is assessing a client and identifies the finding picture below. which metabolic disorder does the nurse suspect? a. hyperthyroidism b. diabetes type 2 c. hypoparathyroidism

c. hypoparathyroidism

all of the following should be included when the nurse performs a mobility assessment of an older client except: a. observe the ability to get out of the chair b. observe gait as the client walks towards the nurse c. observe curve of spine as the client bends over to touch toes d. observe the ability to turn while walking

c. observe curve of spine as the client bends over to touch toes the mobility assessment should include gait, balance, and ability to change position. Curvature of the spine is not part of a mobility assessment

a 19 year old student was diagnosed with hypothyroidism and has started thyroid replacement therapy with levothyroxine (Synthroid). after 1 week she called the clinic to report that she does not feel better. which response from the nurse is correct? a. lets review your diet, it may be causing absorption problems b. it is possible that you did not take your medication as instructed c. the full therapeutic effects may not occur for 3-4weeks d. it will probably require surgery for a cure to happen

c. the full therapeutic effects may not occur for 3-4weeks patients need to understand that it may take up to see 3-4weeks to see full therapeutic effects of thyroid drugs

the nurse is discharging a female client with a new diagnosis of Multiple Sclerosis. which of the following is important to include in the discharge instructions? a. the use of clonazepam to treat episodes of fatigue b. monitor for glucose intolerance prior to conception c. the need to discontinue MS medications prior to attempting to conceive d. suggest the male partner use sidenafil while attempting to conceive

c. the need to discontinue MS medications prior to attempting to conceive many MS medications may be harmful to the fetus. the client with ms should discontinue all medications prior to attempting to conceive. clonazepam is used to treat pain

the nurse is assessing a client with ascites due to cirrhosis. what related complication should the nurse monitor with this client? a. bleeding due to fragile vasculature b. hematemesis due to absence of clotting factor c. worsening ascites due to sodium and water retention d. ecchymosis due to thrombocytopenia

c. worsening ascites due to sodium and water retention

all of the following nursing diagnoses are appropriate for the nurse to use when caring for a group of clients with problems with mobility, except: a. body image, disturbed b. chronic pain syndrome c.hypothermia d.mobility: physical impaired

c.hypothermia

two hours after the application of a fiberglass cast, the client complains of severe pain. what should the nurse fo first? a. elevate the limb on two pillows b. provide pain medication c. notify the healthcare provider d. apply ice to the limb

d. apply ice to the limb complaints of severe pain could indicate compartment syndrome. the first thing the nurse should do is apply ice to reduce inflammation. nurse needs to apply ice and contact healthcare provider

A nurse is receiving report from the off-going nurse. the off-going nurse reports the client has been given the scheduled Regular insulin at 0640 on awakening. it is now 0730 and breakfast trays arrive at 0800. which of the following is an appropriate response by the nurse? a. ask the UAP to check clients blood sugar while the nurse checks to see if the breakfast tray is on the way b. finish report while waiting until the breakfast trays arrive c.have the UAP check the clients blood sugar and provide a cup of juice d. ask the UAP to check the client's blood sugar while the nurse provides some graham crackers until his breakfast tray arrives

d. ask the UAP to check the client's blood sugar while the nurse provides some graham crackers until his breakfast tray arrives

when teaching about hypoglycemia, the nurse will make sure that the patient is aware of the early signs of hypoglycemia including: a. nausea and diarrhea b. hypothermia and seizures c. fruity, acetone odor to the breath d. confusion and sweating

d. confusion and sweating early symptoms of hypoglycemia include the central nervous system manifestations of confusion, irritability, tremor and sweating. hypothermia and seizures are later symptoms of hypoglycemia

the nurse is assessing a client with a cast on the right forearm. which of the following is the most concerning assessment finding and should be reported to the HCP immediately? a. capillary refill 2 seconds b. skin blanches and returns to color in 2 seconds c. itching under the cast d. fingers cool, pale, and numb

d. fingers cool, pale, and numb

a patient who is taking propylthiouracil PTU for hyperthyroidism wants to know how this medicine works. which explanation by the nurse is accurate? a. it blocks the action of thyroid hormone b. it destroys overactive cells in the thyroid gland c. it in activates already existing thyroid hormone in the bloodstream d. it slows down the formation of thyroid hormone

d. it slows down the formation of thyroid hormone

the client asks the nurse i am not sure why i am having so many problems with concentrating. is this part of my multiple sclerosis? which of the following is an appropriate response? a. multiple sclerosis is a progressive, degenerative disorder that can cause disruption to the nerve endings in the brain b. bone inflammation will destroy skeletal muscles which then leads to nerve damage causing multiple sclerosis c. there is no known cause for multiple sclerosis so the pathway of damage is not understood d. multiple sclerosis is unpredictable and the disease destroys parts of the nerves causing disruption in nerve function. this may be why you are having trouble concentrating

d. multiple sclerosis is unpredictable and the disease destroys parts of the nerves causing disruption in nerve function. this may be why you are having trouble concentrating

the client is ordered to have 10 pounds of buck traction placed on the right leg. the UAP has assisted the client on and off the bedpan. the nurse should intervene when the UAP does which of the following? a. uses a fracture bedpan b. asks the client to lift buttocks to be placed on the bedpan c. protects foam boot from bedpan spillage d. places the weight on the floor

d. places the weight on the floor in order for traction to be effective, the weights must be able to hang freely, thus the weights should not be placed on the floor. buck traction is weights attached via a pulley system that are attached to a foam boot. a fracture bedpan is appropriate.

the hcp orders neomycin and lactulose for a client with liver cirrhosis and an ammonia level of 92 mcg/dL. the nurse recognizes that neomycin is being order to: a. reduce the patients risk for infection since the liver cannot filter toxins as effectively b. increase the patients ability to fight infection through the breakdown of bacteria found in the lobby c.increase cholesterol which is produced by the liver and can decrease with liver impairment d. reduce the bacteria found in the bowel that breakdown protein which causes increase ammonia

d. reduce the bacteria found in the bowel that breakdown protein which causes increase ammonia

which of the following is an appropriate intervention for the nurse to implement for an older client with parkinson's disease to appropriately manage their diet at home? a. use a slice of bread to scoop up food, rather than utensils b. ensure each meal is rich in easily digestible proteins c. ask a family member to be present during meals to assist with feeding d. use assistive devices such as electric can openers to aid in meal preparation

d. use assistive devices such as electric can openers to aid in meal preparation

the nurse is observing the UAP obtain vital signs on a morbidity obese client. the nurse should intervene when the UAP does which of the following? a. obtains an oxygen saturation using the ear lobe b. obtains a temperature using the axillary route c. uses the pulse in the wrist to obtain a pulse reading d. uses a standard adult size blood pressure cuff

d. uses a standard adult size blood pressure cuff use of an inappropriate size of sphygmomanometer is a common source of error measuring blood pressure in patients with obesity

a client becomes dizzy while ambulating with a nurse for the first time after surgery and starts to fall forward. which action should the nurse take first? a. have the client look down b. tighten the grip on the gait belt c. pull up on the clients arms d. widen own stance

d. widen own stance since the patient is starting to fall forward the nurse should first widen stance