Exam 3 Reading Assessments

A client calls the nurse to the room and appears very agitated because his breakfast hasn't arrived yet. The nurse notes the client is diaphoretic and has cool, clammy skin. Which of the following would be the nurses priority? 1. Assess the clients blood sugar 2. Offer the client a snack while waiting for the breakfast tray 3. Bring the client some juice 4. Administer regular insulin

1. Assess the clients blood sugar

The nurse is teaching a health promotion and prevention class on CVA risk factors and knows which of the following should be included? (Select all that apply) 1. Atherosclerosis 2. Oral contraceptive use 3. Atrial fibrillation 4. Sinus bradycardia 5. Low BMI

1. Atherosclerosis 2. Oral contraceptive use 3. Atrial fibrillation

A client is admitted to the hospital with newly diagnosed type 1 diabetes. The client is scheduled for a rapid acting insulin prior to meals. Which of the following medications would the nurse anticipate the client have ordered? 1. Lispro insulin 2. Regular insulin 3. Glargine insulin 4. NPH insulin

1. Lispro insulin

A client with a hip fracture has undergone surgery for insertion of a femoral head prosthesis. Which activity should the nurse instruct the client to avoid? 1. Crossing legs while sitting down 2. Sitting on a raised commode 3. Using an abductor splint while lying on the side 4. Rising straight from the chair to a standing position

1. Crossing legs while sitting down

A client has a left tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the fracture despite the morphine injection administered 30 minutes ago. What should the nurse assess first? 1. Distal pulses 2. Pain with a radiating scale 3. Vital sign changes 4. Potential for drug tolerance

1. Distal pulses

An unconscious client with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? 1. Establish an airway 2. Check for a neck fracture 3. Stop bleeding from open wounds 4. Determine the identity of the client

1. Establish an airway

A client with osteoarthritis will undergo an arthrocentesis on a painful, edematous knee. What information should be included in the nursing plan of care? (Select all that apply) 1. Explain the procedure 2. Administer preoperative medications 1 hour before surgery 3. Instruct the client to immobilize the knee for 2 days after the surgery 4. Assess the site for bleeding 5. Offer pain medication

1. Explain the procedure 4. Assess the site for bleeding 5. Offer pain medication

A client in the postanesthesia care unit with a left bbelow-the-knee amputation has pain in his left big toe. What should the nurse do first? 1. Give the client the prescribed opioid analgesic 2. Tell the client it is impossible to feel the pain 3. Explain to the client that the pain is real 4. Show the client that the toes are not there

1. Give the client the prescribed opioid analgesic

The nurse is assessing a client for neurologic impairment after a total hip replacement. Which finding indicates impairment in the affected extremity? 1. Inability to move 2. Decreased distal pulses 3. Diminished capillary refill 4. Coolness to the touch

1. Inability to move

Which of the following would the nurse educate to a client with newly diagnosed type 2 diabetes to prevent a diabetic complication? 1. Inspect feet daily for cracks or cuts 2. Limit exercise to 10 minutes per day 3. Increase fluid intake to maintain hydration 4. Continue regular check-up's and blood work

1. Inspect feet daily for cracks or cuts

A client is scheduled to undergo a cardiac angiogram. Which of the following medications would the nurse have the client hold (not take) prior to the angiogram? 1. Metformin 2. Glyburide 3. NPH insulin 4. Aspirin

1. Metformin

A client presents to the emergency department with an elevated blood sugar. Which of the following symptoms would the nurse expect? Select all that apply. 1. Polydipsia 2. Polyuria 3. Polyphagia 4. Anorexia 5. Oliguria

1. Polydipsia 2. Polyuria 3. Polyphagia

The nurse is caring for an adult with a compound fracture of the right femur and has been placed in skeletal traction. What is the intended outcome of the traction? 1. Reduce and immobilize the fracture 2. Preserve normal length of the leg 3. Prevent movement in bed 4. Prevent skin breakdown

1. Reduce and immobilize the fracture

When admitting a client with a fractured extremity, what area should the nurse assess first? 1. The area distal to the fracture 2. The actual fracture site 3. The area proximal to the fracture 4. The opposite extremity for baseline comparison

1. The area distal to the fracture

A nurse is caring for a client who has had a stroke involving the left hemisphere. Which of the following alterations in function should the nurse expect? (Select all that apply) 1. Poor impulse control and judgement 2. Expressive aphasia 3. Reading difficulty 4. Recognizing familiar objects 5. Spatial awareness

2. Expressive aphasia 3. Reading difficulty 4. Recognizing familiar objects

A client is at risk for increased intracranial pressure (ICP). Which finding is the priority for the nurse to monitor? 1. Unequal pupil size 2. Tachycardia 3. Decreasing body temperature 4. Decreasing systolic blood pressure

1. Unequal pupil size

What is the expected outcome of thrombolytic drug therapy for stroke? 1. Vasoconstriction 2. Increased vascular permeability 3. Dissolved emboli 4. Prevention of a hemorrhage

3. Dissolved emboli

Which of the following client statements would indicate an understanding of their diagnosis of T1D? 1. "I could've prevented this disease by not eating so much sugary foods" 2. "I will need to be on insulin for life because my body doesn't make insulin" 3. "I may start out on oral medications but then may be moved to insulin injections" 4. "I will need to modify my lifestyle in order to eliminate this disease"

2. "I will need to be on insulin for life because my body doesn't make insulin"

A nurse is educating a client on how to properly manage their diabetes while sick. Which of the following statement made by the client requires further education of sick day care? 1. "I will check my blood sugar more often while I am sick" 2. "I will not take my insulin if I am sick" 3. "I will call my doctor if I have a fever for more than 24 hours" 4. "I will be sure to drink fluid even though I don't feel well"

2. "I will not take my insulin if I am sick"

The nurse enters a client's room and finds him unresponsive but breathing and with a pulse. The nurse assesses the blood sugar and the result is 50mg/dL. Which of the following nursing interventions would the nurse prioritize? 1. Administer 6 oz of orange juice 2. Administer 50% IV dextrose 3. Administer glucose tablets 4. Administer a normal saline IV drip

2. Administer 50% IV dextrose

A client presents to the hospital with a blood sugar of 38mg/dL. Which of the following signs and symptoms would the nurse anticipate seeing in this client. (Select all that apply). 1. Extreme thirst 2. Confusion 3. Polyuria 4. Diaphoresis 5. Shakiness

2. Confusion 4. Diaphoresis 5. Shakiness

The nurse is teaching the family of a client with dysphagia about decreasing the risk of aspiration while eating. which strategies should the nurse include in the teaching plan? (Select all that apply) 1. Restricting the diet to liquids until swallowing improves 2. Maintain an upright position while eating 3. Introducing foods on the unaffected side of the mouth 4. Cutting food into large pieces of finger foods 5. Keeping distractions to a minimum

2. Maintain an upright position while eating 3. Introducing foods on the unaffected side of the mouth 5. Keeping distractions to a minimum

What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke? 1. Bowel sounds 2. Pupil size and pupillary response 3. Cholesterol level 4. Echocardiogram

2. Pupil size and pupillary response

A nurse is caring for a client who has increased intracranial pressure. Which of the following interventions should the nurse take? 1. Encourage patient to cough and deep breathe 2. Instruct the patient to drink at least 2000 ml of clear fluid a day 3. Elevate the head of the bed 4. Provide a brightly lit environment

3. Elevate the head of the bed

A nurse caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. Their blood glucose is checked and found to be 48mg/dl. The nurse should give the client which of the following? 1. 4 oz skim milk 2. 4 oz diet soda 3. Graham crackers 4. 1 teaspoon sugar

3. Graham crackers

A nurse is caring for her patient who just had a transient ischemic attack, and recognizes they are now at increased risk for: 1. Meningitis 2. Increased intracranial pressure 3. Seizures 4. A CVA

4. A CVA

The health care provider has prescribed phenytoin sodium therapy for a client with seizures. What should the nurse explain to the client about suddenly stopping the medication? 1. A hypoglycemic reaction is likely 2. Heart block can occur 3. Physical dependency develops over time 4. Status epilepticus may occur

4. Status epilepticus may occur