exam 4 adaptive questions, Pharmacology Ch 4
What parts of the syringe must remain sterile?
The tip and inside
When using the airlock technique how do you hold the needle
Perpendicular to the site you are injecting
What 3 types of drugs are used in IM injections?
Irritating drugs, aqueous suspensions, solutions and oils (FYI: ex includes: codeine, morphine)
Intradermal injection sites
Locations are chosen so that an inflammatory reaction can be observed. Preferred areas are lightly pigmented, thinly keratinized, and hairless, such as: -the ventral mid-forearm, -clavicular area of the chest, and -scapular area of the back.
How do you read an intradermal result?
Make sure to tell the patient not to wash off the marker, measure the diameter of the local action (don't include any erythema in measurement) assess the area sighting 24-78 hrs
A nurse is caring for a client with type 1 diabetes who developed ketoacidosis. Which laboratory value supports the presence of diabetic ketoacidosis? 1 Increased serum lipids 2 Decreased hematocrit level 3 Increased serum calcium levels 4 Decreased blood urea nitrogen level
1 With diabetic ketoacidosis serum lipid levels are high because of the increased breakdown of fat. Serum lipid levels can go so high that the serum appears opalescent and creamy. With diabetic ketoacidosis the hematocrit level generally is increased because of dehydration. The calcium level is unrelated to diabetic ketoacidosis. With diabetic ketoacidosis the blood urea nitrogen level generally is increased because of dehydration.
A client with cancer of the thyroid is scheduled for a thyroidectomy. Postoperatively the nurse plans to have a: 1 Quiet, dimly lit room for the client 2 Tracheostomy set at the client's bedside 3 Large soft pillow for use under the client's head 4 Suction machine set on intermittent suction at the client's bedside
2 A tracheostomy set should be available in the event there is excessive edema at the surgical site, which can cause tracheal compression. A quiet, dimly lit room for the client is not necessary after a thyroidectomy. The head should be kept in anatomical alignment, the neck not flexed or hyperextended; a small soft pillow can be used to accomplish alignment. Intermittent suction does not provide the constant suction needed to clear the airway.
Postoperatively a client who had a thyroidectomy complains of tingling and numbness of the fingers and toes, and the nurse observes muscle twitching. Which complication does the nurse suspect the client is experiencing? 1 Hypokalemia 2 Hypocalcemia 3 Thyrotoxic crisis 4 Hypovolemic shock
2 The signs and symptoms presented in the question indicate hypocalcemia. Injury to the parathyroid glands during a thyroidectomy results in a deficiency of parathormone, which decreases calcium levels in the blood. Hypokalemia is characterized by generalized weakness, a decrease in reflexes, shallow respirations, and cardiac dysrhythmias. Thyrotoxic crisis is characterized by tachycardia, hyperpyrexia, and an exacerbation of hyperthyroid symptoms. Hypovolemic shock is characterized by a weak, thready pulse and hypotension.
The nurse is caring for a client newly diagnosed with diabetes. When preparing the teaching plan about the importance of yearly eye examinations, the nurse should plan to instruct the client on which eye problem most associated with diabetes? 1 Cataracts 2 Glaucoma 3 Retinopathy 4 Astigmatism
3 Diabetic retinopathy is a leading cause of blindness in diabetics. Glaucoma and cataracts also are associated with diabetes, but retinopathy is the most common eye problem. Astigmatism is not associated with diabetes.
What are 3 advantages of IM injections?
1) More rapid effect, 2) drugs that are irritating to the subQ can be given IM, 3) larger volumes can be given
How much injection do you use for the dgluteal??
1-3 ml
What syringes are used for IM injections?
1-3 ml
What size of syringe is used for subQ injections and how much is usually injected?
1-3ml; 0.5-1.5ml injected
What site is preferred for pediatric younger than 7 months?
Bastia lateralis
What is important to do after using a filter needle?
Change the needle to prevent irritation
Who is vastus lateralis injections mostly used for?
Children
How is the drug inserted into the body and what effects does it have? (IV)
Directly into the blood, action occurs almost immediately
What must you not do and tell the patient not to do after a transdermal injection?
Don't rub it!
What effect does a subQ have on the body?
Systemic effect
What needle do you use to draw up meds from an ampule or glass vial?
Filter needle
How do you cleanse an area for injection?
From inside to out in a circular motion.
What are some rules about age with injection sites?
VL is used for people with firm walking development, If they don't have firm walking development then VG is prefered DO NOT USE DG FOR CHILDREN
When can you use the z track?
Vgluteal and dglutteal
What are 2 disadvantages to IM injections?
Volumes over 3 will not be absorbed properly, divide doses if over 3.
The nurse is teaching a client newly diagnosed with diabetes about the importance of glucose monitoring. Which of the following blood glucose levels should the nurse identify as hypoglycemia? a. 58 mg/dL b. 68 mg/dL c. 78 mg/dL d. 88 mg/dL
a Clients who have blood glucose levels below 60 may experience hypoglycemia; 70 mg/dL, 78 mg/dL, and 88 mg/dL are normal blood glucose levels.
What volume of drug is used for deltoid injections??
0.5-1ml, no more than 2ml
What drug is only injected through the dgluteal?
5 gamma globulin
What are two disadvantages of subQ injections?
Absored more slowly than IM, and you can't inject more than 1.5 ml of drugs
What is the parenteral route? Name 8 examples.
Anything given by needle, subQ, IM, IV, intra-dermal, intra-lesional, intra-arterial, intra-cardiac, intra-articular (jess mneumonic: calm davsq)
How do you locaate the deltoid injection site?
Draw an imaginary line across the armpit at the level of the axilla and then lower edge of the acromion
What are four examples of subQ injections?
Heparin, insulin, epinephrine and allergy meds (jess remembrance: subq= in epi hell -->insulin, epinepherine heparin, allergy...)
What is the rule when using the deltoid site on infants?
If the amount is very small
What is the deltoid injection not suitable for?
More than one injection a day
The nurse is administering medications to an infant. What intervention is the best technique for the nurse to use?
Move slowly and have a non-threatening approach.
What syringe do you use for volumes smaller than 0.5 ml
TB
Do you aspirate with subQ injections?
Yes
The 3-year-old client has an IM medication ordered. What is the most appropriate approach to gain the child's cooperation? a) Engage in fantasy play b) Give injection to a stuffed toy bear c) Restrain the client's upper extremities d) Ask family members to leave the room
b) Give injection to a stuffed toy bear
When providing care for a client in the first 24 hours after a thyroidectomy, the nurse should: 1 Check the back and sides of the operative site 2 Support the head during mild range-of-motion (ROM) exercises 3 Encourage the client to ventilate feelings about the surgery 4 Advise the client that regular activities can be resumed immediately
1 Bleeding may occur, and blood will pool in the back of the neck because the blood will flow via gravity. ROM exercises will increase pain and put tension on the suture line. Talking should be avoided in the immediate postoperative period except to assess for a change in pitch or tone, which may indicate laryngeal nerve damage. Activity should be resumed gradually, and frequent rest periods encouraged.
A client with type 1 diabetes self-administers NPH insulin (Novolin N) every morning at 8:00 AM. The nurse concludes that the client understands the action of this insulin when the client says, "I should be alert for signs of hypoglycemia between: 1 12 PM and 8 PM." 2 10 AM and 1 PM." 3 10 PM and midnight." 4 8:30 AM and 9:30 AM."
1 NPH insulin's onset of action is 1.5 to 4 hours, peak action is 4 to 12 hours, and duration of action is 18 to 24 hours; if hypoglycemia occurs, it will happen most likely between 12 PM and 8 PM. Regular insulin (Novolin R) peaks in 2 to 5 hours. No insulin peaks in 14 to 16 hours. Lispro (Humalog) peaks in 30 minutes to 1.5 hours.
A client is admitted to the hospital with a diagnosis of cancer of the thyroid gland, and a thyroidectomy is performed. What should the nurse do during the first six to eight hours after the surgery? 1 Place two pillows behind the client's head. 2 Monitor for the complication of tetany resulting from hypocalcemia. 3 Assess the sides and back of the client's neck for evidence of bleeding. 4 Encourage the client to perform deep-breathing and coughing exercises.
3
A client returns from surgery after a thyroidectomy. What should the nurse do to assess unilateral injury of the laryngeal nerve? 1 Assess swallowing. 2 Check the neck for edema. 3 Observe for signs of tetany. 4 Evaluate the client's speech.
4 If the laryngeal nerve is damaged during surgery, the client will be hoarse and will have difficulty speaking. Assessing swallowing is not indicative of laryngeal nerve injury. Checking the neck for edema and observing for signs of tetany are not indicative of laryngeal nerve injury.
A nurse is caring for an alert client who has diabetes and is receiving an 1800-calorie American Diabetic Association diet. The client's blood glucose level is 30 mg/dL. The healthcare provider's protocol calls for treatment of hypoglycemia with 15 g of a simple carbohydrate. The nurse should: 1 Provide 12 ounces of non-diet soda 2 Give 25 mL dextrose 50% by slow intravenous (IV) push 3 Have the client drink 8 ounces of fruit juice 4 Ask the client to ingest one tube of glucose gel
4 One tube of glucose gel contains 15 g of carbohydrate and is the most appropriate intervention in this situation. Providing 12 ounces of non-diet soda is too much carbohydrate; 4 to 6 ounces is adequate. Administering dextrose by IV push is not appropriate for an alert client who is able to eat and drink. Having the client drink 8 ounces of fruit juice is too much carbohydrate; 4 to 6 ounces is adequate.
The major nursing concern when caring for a client with the diagnosis of hyperthyroidism is: 1 Monitoring for hypoglycemia 2 Protecting visitors and staff from radiation exposure 3 Providing foods to increase appetite 4 Arranging for sufficient rest periods
4 Promotion of rest to reduce metabolic demands is a challenging but essential task for a client who has hyperthyroidism. With hyperthyroidism, glucose tolerance is decreased, and the client is hyperglycemic. There is no indication that radioactive iodine has been given; therefore, the client does not emit radiation. The client will have an increased appetite.
What angle should the needle for a deltoid injection
90* to the skin or towards the acromion.
What is dangerous about thee dgluteal?
It is close to nerves and blood vessels
What is 1 reason you would choose dgluteal over vgluteal?
Vgluteal is safer (less danger of injury to major nerves and vascular structures) +less painful, -but you can't put in as much volume
What is the vollume of drugs for vastus lateralis for infants and adults?
<0.5 ml forr infannts 1 ml max, 1-1.5 ml ofor adults 2 ml max
What are the best areas for intradermal injections and examples? Why?
Light pigmented, low keratinized, hairless: ventral forearm, clavicular area of the chest, scapulae are of the back. (Because these are areas that inflammatory action can be observed, pg 41 text)
How do you inject medication with the Z-track??
Pull the skin, subQ tissues, and fat laterally, while holding the skin put in the needle -->inject the drug, AFTER the drug is injected, withdraw the needle & release the tissue at the same time, this prevents back fllow into the subQ
Why would you chose the vgluteal over the dgluteal?
Thinner layer of subQ, less painful
What are the 4 injection sites for IM?
Ventrogluteal, dorsogluteal, deltoid, vastus laterallis
Why is the z-track technique used?
When a drug is highly irritating to the subQ tissues or has the ability to permanently stain the skin
When would the nurse plan to use Z-track technique for the administration of an intramuscular injection?
With medications that are known to be irritating, painful, and/or staining to tissues The Z-track method prevents medication from leaking into subcutaneous tissues where it can be irritating and/or painful.
A client with type 1 diabetes has an above-the-knee amputation because of severe lower extremity arterial disease. What is the nurse's primary responsibility two days after surgery when preparing the client to eat dinner? 1 Checking the client's serum glucose level 2 Assisting the client out of bed into a chair 3 Placing the client in the high-Fowler position 4 Ensuring the client's residual limb is elevated
1 Because the client has type 1 diabetes, it is essential that the blood glucose level be determined before meals to evaluate the level of control of diabetes and the possible need for insulin coverage. To prevent flexion contractures of the hip, the client should not sit for a prolonged time; this is not the priority. Raising the head of the bed flexes the hips, which may result in hip flexion contractures; this is not the priority. Ensuring the client's residual limb is elevated may result in a hip flexion contracture and should be avoided.
When preparing a client for discharge after a thyroidectomy, the nurse teaches the signs of hypothyroidism. The nurse evaluates that the client understands the teaching when the client says, "I should call my health care provider if I develop: 1 Dry hair and an intolerance to cold." 2Muscle cramping and sluggishness." 3Fatigue and an increased pulse rate." 4Tachycardia and an increase in weight."
1 Dry, sparse hair and cold intolerance are characteristic responses to low serum thyroxine. Muscle cramping is associated with hypocalcemia. Low thyroxine levels reduce the metabolic rate, resulting in fatigue, but do not increase the pulse rate. Low thyroxine levels reduce the metabolic rate, resulting in weight gain and bradycardia, not tachycardia.
The nurse is caring for an older client who is admitted to the hospital with a diagnosis of type 2 diabetes. The nurse recalls that older adults with type 2 diabetes: 1 Seldom develop ketoacidosis 2 Secrete no endogenous insulin 3 Have a lower risk of complications 4 Develop a sudden onset of symptoms
1 Lipolysis is not a common response to meeting the metabolic needs of those with type 2 diabetes; therefore, ketones are not present in large enough amounts to cause ketoacidosis. Adults with type 2 diabetes do secrete endogenous insulin, but secretion is slow and in smaller than adequate amounts. The incidence of chronic complications depends on the level of glucose control, not developmental level. The onset of type 2 diabetes usually is gradual, whereas in type 1 diabetes, it is sudden and dramatic.
A nurse is caring for a client who just had a thyroidectomy. For which client response should the nurse assess the client when concerned about an accidental removal of the parathyroid glands during surgery? 1 Tetany 2 Myxedema 3 Hypovolemic shock 4 Adrenocortical stimulation
1 Parathyroid removal eliminates the body's source of parathyroid hormone (parathormone), which increases the blood calcium level. The resulting low body fluid calcium affects muscles, including the diaphragm, resulting in dyspnea, asphyxia, and death. Loss of the thyroid gland will upset thyroid hormone balance and may cause myxedema. The parathyroids are not involved in regulating plasma volume; the pituitary and adrenal glands are responsible. The parathyroids do not regulate the adrenal glands.
A client with adrenal insufficiency reports feeling weak and dizzy, especially in the morning. What should the nurse determine is the most probable cause of these symptoms? 1 A lack of potassium 2 Postural hypertension 3 A hypoglycemic reaction 4 Increased extracellular fluid volume
3 Deficiency of glucocorticoids causes hypoglycemia in the client with Addison disease. Clinical manifestations of hypoglycemia include nervousness; weakness; dizziness; cool, moist skin; hunger; and tremors. Hypokalemia is evidenced by nausea, vomiting, muscle weakness, and dysrhythmias. Weakness with dizziness on arising is postural hypotension, not hypertension. An increased extracellular fluid volume is evidenced by edema, increased blood pressure, and crackles.
An insulin pump is instituted for a client with type 1 diabetes. The nurse plans discharge instructions. Which short-term goal is the priority for this client? 1. "Adhere to the medical regimen." 2"Remain normoglycemic for three weeks." 3. "Demonstrate correct use of the insulin pump." 4"List three self-care activities that help control the diabetes."
3 Demonstrating correct use of the insulin pump is the short-term, client-oriented goal necessary for the client to manage the pump and avoid hypo- and hyperglycemia; this outcome can be measured by observing a return demonstration by the client. Adhering to the medical regimen is not a short-term goal. Remaining normoglycemic for three weeks is measurable, but requires the client to manage the insulin pump. Although listing three self-care activities that help control the diabetes is a measurable short-term goal, it is not the priority when the client must master use of the insulin pump.
Which clinical indicator should the nurse identify as expected for a client with type 2 diabetes? 1 Ketones in the blood but not in the urine. 2 Glucose in the urine but not hyperglycemia. 3 Urine negative for ketones and hyperglycemia. 4 Blood and urine positive for both glucose and ketones
3 In type 2 diabetes, there is sufficient insulin production to prevent fat breakdown that leads to ketones, but insulin resistance leads to hyperglycemia. Ketones in the blood but not in the urine does not occur with either type. In type 2 diabetes, there is sufficient insulin production to prevent fat breakdown that leads to ketones, but insulin resistance leads to hyperglycemia and diabetes mellitus. Glucose in the urine but not hyperglycemia is impossible; if glycosuria is present, the level of glucose in blood first must exceed the renal threshold of 160 to 180 mg/dL. Blood and urine positive for both glucose and ketones is expected in uncontrolled type 1 diabetes.
A client is scheduled to have a thyroidectomy. Which medication does the nurse anticipate the health care provider will prescribe to decrease the size and vascularity of the thyroid gland before surgery? 1 Vasopressin (Pitressin) 2 Propylthiouracil (PTU) 3 Potassium iodide (SSKI) 4 Levothyroxine (Synthroid)
3 Potassium iodide adds iodine to the body fluids, exerting negative feedback on the thyroid tissue and decreasing its metabolism and vascularity. Vasopressin is a pituitary hormone. Propylthiouracil interferes with production of thyroid hormone but causes increased vascularity and size of the thyroid. Levothyroxine is a thyroid hormone that may be administered after a thyroidectomy if the client develops hypothyroidism.
A client is diagnosed with type 2 diabetes, and the health care provider prescribes an oral hypoglycemic. For what side effect should the nurse teach this client to monitor? 1 Ketonuria 2 Weight loss 3 Ketoacidosis 4 Low blood sugar
4 Oral hypoglycemic agents decrease serum glucose levels that may precipitate hypoglycemia. Ketonuria occurs with insulin-dependent diabetes. Weight gain usually is noted in adult-onset diabetes. Ketoacidosis occurs with insulin-dependent diabetes.
A nurse explains to a client with diabetes that self-monitoring of blood glucose is preferred to urine glucose testing because blood glucose testing is: 1 More accurate 2 Easier to perform 3 Done by the client 4 Not influenced by drugs
1 Blood glucose testing is a more direct and accurate measure; urine testing provides an indirect measure that can be influenced by kidney function and the amount of time the urine is retained in the bladder. Whereas blood and urine testing is relatively simple, testing the blood involves additional knowledge. Both procedures can be done by the client. Whether or not it is influenced by drugs is not a factor. Although some urine tests are influenced by drugs, there are methods to test urine to bypass this effect.
A client is diagnosed with hyperthyroidism and surgery is scheduled because the client refuses ablation therapy. While awaiting the surgical date, the nurse plans to instruct the client to: 1 Consciously attempt to calm down 2 Eliminate coffee, tea, and cola from the diet 3 Keep the home warm and use an extra blanket at night 4 Schedule activities during the day to overcome lethargy
2 Coffee, tea, and cola contain caffeine, which may increase thyroid activity. Hyperactivity is a physiological response; it is not under conscious control. The increased metabolic rate associated with hyperthyroidism will make the client feel warm; a cool environment is needed. Hyperactivity is a problem, and the client should be encouraged to rest.
The health care provider prescribes daily fasting blood glucose levels for a client with diabetes mellitus. The goal of treatment is that the client will have glucose levels within the range of: a. 40 to 65 mg/dL of blood b. 70 to 105 mg/dL of blood c. 110 to 145 mg/dL of blood d. 150 to 175 mg/dL of blood
2 70 to 105 mg/dL of blood is the expected range for blood glucose. The ranges of 40 to 65 mg/dL of blood, 110 to 145 mg/dL of blood, and 150 to 175 mg/dL of blood are indicative of hypoglycemia.
A client with hyperthyroidism is treated initially with propylthiouracil (PTU). What should the nurse include when teaching the client about this medication? 1 This medication will have to be taken for the remainder of the client's life 2 Symptoms may not subside until the client has taken the medication for several weeks. 3 Milk should be taken with the medication so that gastric irritation does not occur 4 The medication should be taken between meals so that it is more readily absorbed
2 This drug does not interfere with thyroxine already stored in the gland; symptoms remain until the hormone is depleted. Duration of therapy varies depending on the severity of the disease and the client's response to therapy. Milk does not need to be taken because this drug is not irritating to mucosal tissue, and no special precautions are necessary. Absorption is not affected by the presence of food in the stomach.
What equipment is used for intradermal injections? Needle gauge, length of needle, syringe...
25-27 gauge, 3/8-5/8" long, 1ml (tb)
The nurse is caring for a client with diabetes mellitus. The nurse recalls that the primary fluid shift that occurs with this condition is: 1 Intravascular to interstitial because of glycosuria 2 Interstitial to extracellular because of hypoproteinemia 3 Intracellular to intravascular because of hyperosmolarity 4 Intercellular to intravascular because of increased hydrostatic pressure
3 The osmotic effect of hyperglycemia pulls fluid from the intracellular and interstitial compartments, resulting in dehydration. Hyperglycemia pulls fluid from the interstitial to the intravascular compartment, eventually spilling into the urine. Interstitial fluid is part of the extracellular compartment; the osmotic pull of glucose exceeds other osmotic forces. An increase in hydrostatic pressure results in an intravascular to interstitial shift.
The nurse is caring for a client newly diagnosed with diabetes. The nurse should teach the newly diabetic client that which hypoglycemic symptom is one of the most common? 1 Kussmauls respirations 2 Tachycardia 3 Confusion 4 Anorexia
3 The most common symptoms of hypoglycemia are nervousness, weakness, perspiration, and confusion. Kussmauls respirations are associated with hyperglycemia or ketoacidosis. Bradycardia is associated with hypoglycemia, tachycardia is not. Anorexia is associated with hyperglycemia.
Do you put subQ injections in the same site?
NO!
What type of effect does the IM injection cause?
systemic
The nurse administers a variety of medications to the client. Which comment by the client indicates need for further teaching? a)"I do not drink or eat when I have nitroglycerin in place." b) "I mix all these meds in my dessert and hope I am not too full to finish." c) "I keep the meds in their original labeled containers." d) "I store medications away from children and pets."
b) "I mix all these meds in my dessert and hope I am not too full to finish."
A nurse is assessing a client for possible laryngeal nerve injury following a thyroidectomy. Which action should the nurse implement on an hourly basis? 1 Ask the client to speak. 2 Instruct the client to swallow. 3 Have the client hum a familiar tune. 4 Swab the client's throat to test the gag reflex.
1 If the laryngeal nerves are injured bilaterally during surgery, the vocal cords will tighten, interfering with speech. If one cord is affected, hoarseness develops. This can be evaluated simply by having the client speak every hour. Swallowing, humming, and the gag reflex are not influenced by laryngeal nerve damage.
A client with untreated type 1 diabetes mellitus may lapse into a coma because of acidosis. An increase in which component in the blood is a direct cause of this type of acidosis? 1 Ketones 2 Glucose 3 Lactic acid 4 Glutamic acid
1 The ketones produced excessively in diabetes are a by-product of the breakdown of body fats and proteins for energy; this occurs when insulin is not secreted or is unable to be used to transport glucose across the cell membrane into the cells. The major ketone, acetoacetic acid, is an alpha-ketoacid that lowers the blood pH, resulting in acidosis. Glucose does not change the pH. Lactic acid is produced as a result of muscle contraction; it is not unique to diabetes. Glutamic acid is a product of protein metabolism.
A client has a new diagnosis of hyperthyroidism. Which skin conditions should the nurse expect when performing a physical assessment? Select all that apply 1 Warm 2 Moist 3 Pale 4 Smooth 5 Coarse 6 Dry
1,2,4 Hyperfunction of the thyroid gland causes diaphoresis, making the skin moist, as well as skin that is smooth and warm. Pale, coarse, and dry skin is found with hypothyroidism.
A nurse, caring for a client with uncontrolled diabetes, suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply. 1 Headache 2 Confusion 3 Extreme thirst 4 Profuse sweating 5 Increased urination
1,2,4 Neurologic responses occur when there is an insufficient supply of glucose to the brain, thus causing clinical manifestations such as headache and confusion. Profuse sweating is a classic sign of hypoglycemia. This is triggered by lack of glucose to the nerve cells. Thirst (polydipsia) is a classic symptom of hyperglycemia. Increased urination (polyuria) is a classic sign of hyperglycemia.
The nurse is assessing a client with hyperthyroidism. Which clinical indicators are consistent with this diagnosis? Select all that apply. 1 Emotional lability 2 Dyspnea on exertion 3 Abdominal distension 4 Decreased bowel sounds 5 Hyperactive deep tendon reflexes
1,2,5 Lability of mood is a psychological/emotional manifestation related to excess thyroid hormones. Dyspnea with or without exertion can occur as the body attempts to meet oxygen demands related to the increased metabolic rate associated with hyperthyroidism. Hyperactive reflexes are a neurologic manifestation related to excessive production of thyroid hormones. Abdominal distension is associated with hypothyroidism; it is related to constipation and weight gain. Bowel sounds increase, not decrease, as a result of hyperperistalsis associated with the elevated metabolic rate. Hypoactive bowel sounds are related to hypothyroidism.
Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply. 1. Diarrhea 2. Listlessness 3. Weight loss 4 Bradycardia 5 Decreased appetite
1,3 Excessive thyroid hormones increase the metabolic rate, causing an increase in intestinal peristalsis. Excessive thyroid hormones increase the metabolic rate, causing weight loss. Listlessness occurs with hypothyroidism because of a decreased metabolic rate. A slow pulse rate accompanies hypothyroidism, not hyperthyroidism, because of a decreased metabolic rate. Appetite increases (polyphagia) with hyperthyroidism in an effort to meet metabolic needs.
A client who has had a subtotal thyroidectomy does not understand how hypothyroidism can develop when the problem was initially hyperthyroidism. The nurse bases a response on the fact that: 1 Hypothyroidism is a gradual slowing of the body's function 2 There will be a decrease in pituitary thyroid-stimulating hormone (TSH) 3 There may not be enough thyroid tissue to supply adequate thyroid hormone 4 Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones
3 After a subtotal thyroidectomy the thyroxine output may be inadequate to maintain an appropriate metabolic rate. Hypothyroidism is a decrease in thyroid functioning, not a slowing of the entire body's functions. In hypothyroidism the level of TSH from the pituitary usually is increased. Atrophy of the remaining thyroid tissue does not occur.
During the early postoperative period after a subtotal thyroidectomy, the nursing priority is to assess for: 1 Hemorrhage 2 Thyrotoxic crisis 3 Airway obstruction 4 Hypocalcemic tetany
3 Maintaining airway patency is always the priority to permit gas exchange necessary to maintain life. Although important, hemorrhage, thyrotoxic crisis, and hypocalcemic tetany do not exceed patency of the airway in priority.
Which is the best advice the nurse can give regarding foot care to a client diagnosed with diabetes? 1 Remove corns on the feet 2 Wear shoes that are larger than the feet 3 Examine the feet weekly for potential sores 4 Wear synthetic fiber socks when exercising
4 Research demonstrates that socks with synthetic fibers wick away moisture better than other fabrics when participating in vigorous activities. Self-removal of corns can result in injury to the feet. Shoes that do not fit appropriately will create friction causing sores, blisters, and calluses. The feet should be examined daily, not weekly.
client with type 2 diabetes travels frequently and asks how to plan meals during trips. The nurse's most appropriate response is: 1 "You can order diabetic foods on most airlines and in restaurants." 2 "Plan your food ahead and carry it with you from home." 3 "Monitor your blood glucose level frequently and eat accordingly." 4 "Choose the foods you normally do and follow your food plan wherever you are.
4 According to an individual's needs, consistency and regularity in the food plan should be maintained; this is a basic principle of dietary management of diabetes. Ordering diabetic foods is not necessary; the client can make selections from regular food choices. Planning food ahead and carrying it from home cannot always be done; it is unnecessary because choices can be made within the food plan. The client should follow the food plan.
What angle should you put tthe needle in the VL?
45-60* angle to the frontal, sagital, and horizontal planes of the thigh
How do you insert the needle for subQ needles, especially on those with not a lot of subQ??
45-90*, it depends on body size. 45* for thinner patients
How do you locate the site for vgluteal?
Place hand on greater trochanter of femur, middle finger traces iliac crest -->it is the space between index and middle finger.
The nurse is administering oral medications to the client. Which are important considerations? a) Administer irritating drugs with food b) avoid mixing mediations in infant formula c) enteric coated capsules CAN be chewed or crushed d)Oral medications are not given if client is vomiting.
a) Administer irritating drugs with food b) avoid mixing medications in infant formula d)Oral medications are not given if client is vomiting.
The nurse is teaching the client to use an inhaler. What common teaching points should the nurse remember? a)Handheld nebulizers deliver a large molecule particle spray of medication b) Semi-or high Fowler's position is recommended c) Spacers decrease delivery of medication d) A counter should be used to track the number of inhalations used.
a)Handheld nebulizers deliver a large molecule particle spray of medication d) A counter should be used to track the number of inhalations used. ??? Pg 47 text
A client with type 1 diabetes receives Humulin R insulin in the morning. Shortly before lunch the nurse identifies that the client is diaphoretic and trembling. What is the nurse's most appropriate action? 1 Administer insulin to the client 2 Give the client lunch immediately 3 Encourage the client to drink fluids 4 Assess the client's blood glucose level
4 The client needs glucose, not just fluids. The presence of hypoglycemia should be determined before initiating therapy; Humulin R insulin given in the morning peaks within four hours or just before lunchtime. After hypoglycemia is verified, the client should be given an immediate source of glucose. Administering insulin is contraindicated; the client is experiencing adaptations of hypoglycemia and administering insulin will decrease further an already low blood glucose level. Giving the client lunch may be done after hypoglycemia is determined.
During a routine examination, an enlarged thyroid gland is discovered in a client, and hyperthyroidism is suspected. What clinical findings should the nurse expect to identify when completing a nursing admission history and physical for this client? Select all that apply. 1 Palpitations 2 Tachycardia 3 Thickened skin 4 Apathetic attitude 5 Menstrual disturbances
1,2,5 Hyperthyroidism increases the metabolic rate and the need for oxygen; this results in an increased heart rate and myocardial irritability. Hyperthyroidism increases the metabolic rate and the need for oxygen; this results in an increased heart rate. Menstrual disturbances are associated with hyperthyroidism; women can experience lightened periods or missed periods. hickened skin is associated with hypothyroidism and myxedema. An apathetic attitude is associated with hypothyroidism and myxedema.
A client newly diagnosed with type 1 diabetes receives information about insulin. The client states, "I hate shots. Why can't I take the insulin in pill form?" What is the nurse's best response? 1 "Your diabetic condition is too serious for oral insulin." 2 "Insulin is poorly absorbed and its action is erratic when taken by mouth." 3 "Insulin by mouth causes a high incidence of allergic and adverse reactions." 4 "Once your diabetes is controlled, your physician might consider oral insulin."
2 The chemical structure of insulin is altered by gastric secretions, rendering it ineffective. There is no such thing as oral insulin; this comment about the seriousness of the diabetic condition may increase anxiety. There are no data to support this statement regarding allergic or adverse reactions, and insulin is given parenterally, not orally. Insulin is not absorbed but is destroyed by gastric secretions; there is no insulin that is effective if taken by mouth.
Hoow many attempts can you do to insert an IV
3
Things to remember with Intradermal
-Hold skin taut -insert at 10-15 degree angle -inject slowly as wheal -do not massage the area, tell client not to as well -mark with pen -reassess for allergic reaction in 24-72 hours
Intradermal injection
-Local Effect -Small amount is injected so that volume does not interfere with wheal formation or cause a systemic reaction. -Used for observation of an inflammatory (allergic) reaction to foreign proteins. --Ex:TB, allergy sensitivity, immunotherapy for cancer. Eq: Needle: 25-27 gauge; 3/8-5/8" long -Syringe: 1mL calibrated in 0.01-mL increments (usually 0.01-0.1 mL injected)
Subcutaneous injections
-Systemic effect -Sustained effect; absorbed mainly through capillaries, usually slower in onset than with the IM route -Used for small doses of nonirritating, water-soluble drugs Eq: Needle: 25-27 gauge; 1/2-5/8" long Syringe: 1-3mL (usually 0.5-1.5mL injected) -->Insulin syringe measured in units for use with insulin only
Things to remember with SubQ injections
-pinch the skin -insert at a 45-90 degree angle -Release the skin -Aspirate (except herparin LMWH, and insulin) -Gently massage the area unless contraindicated -Apply bandaid
How much can you inject IM and what must you never go over?
0.5-3mL for adult, 0.5-1mL for child; never over 3 (Usually 0.5-1.5mL injected) (Text page 43)
How much should be injected for adults and children?
0.5-3ml for adults, 0.5-1ml for children
A client has a history of hypothyroidism. Which skin condition should the nurse expect when performing a physical assessment? 1 Dry 2 Moist 3 Flushed 4 Smooth
1 Dry skin is caused by decreased function of sebaceous glands; a paucity of thyroid hormones T3 and T4, which control the basal metabolic rate, can alter the function of almost every body system. The skin will not be flushed; the client will appear pale. Moist and smooth skin occur with hyperfunction of the thyroid and an increase in the basal metabolic rate.
A client is being discharged after having a total thyroidectomy. Which instruction would be most important for the nurse to include? 1 Take thyroid replacement medications as prescribed. 2 Be aware of signs and symptoms of dehydration. 3 Avoid all over the counter medications. 4 Report signs of hypoglycemia.
1 Long term thyroid replacement is prescribed after surgery to replace the thyroid's natural function. Although teaching signs and symptoms of dehydration is a health promotion strategy, it is not the priority. Clients should not be encouraged to avoid all over the counter medications, but instructed to discuss contraindications with their health care provider or pharmacy. Low blood glucose is not attributed to this procedure.
client with hyperthyroidism is to receive methimazole (Tapazole). The nurse should instruct the client that: 1 Initial improvement will take several weeks 2 There are few side effects associated with this drug 3 This medication may be taken at any time during the day 4 Large doses are used to quickly correct the functions of the thyroid
1 Methimazole (Tapazole) blocks thyroid hormone synthesis; it takes several weeks of medication therapy before the hormones stored in the thyroid gland are released and the excessive level of thyroid hormone in the circulation is metabolized. There are many common side effects that include nausea, vomiting, diarrhea, rash, urticaria, pruritus, alopecia, hyperpigmentation, drowsiness, headache, vertigo, and fever. Methimazole should be spaced at regular intervals because blood levels are reduced in approximately eight hours. Large doses cause toxic side effects that can be life threatening, including nephritis, hepatitis, agranulocytosis, leukopenia, thrombocytopenia, hypothrombinemia, and lymphadenopathy.
A client with type 1 diabetes comes to the clinic because of concerns regarding erratic control of blood glucose with the prescribed insulin therapy. The client has been experiencing a sudden fall in the blood glucose level, followed by a sudden episode of hyperglycemia. Which complication of insulin therapy should the nurse conclude that the client is experiencing? 1 Somogyi effect 2 Dawn phenomenon 3 Diabetic ketoacidosis 4 Hyperosmolar nonketotic syndrome
1 The Somogyi effect is a response to hypoglycemia induced by too much insulin; the body responds to the hypoglycemia by counterregulatory hormones stimulating lipolysis, gluconeogenesis, and glycogenolysis, resulting in rebound hyperglycemia. The Dawn phenomenon is hyperglycemia that is present on awakening in the morning because of the release of counterregulatory hormones in the predawn hours; it is thought that growth hormone or cortisol are related to this phenomenon. Diabetic ketoacidosis (diabetic coma) is a profound deficiency of insulin and is characterized by hyperglycemia, ketosis, acidosis, and dehydration. Hyperosmolar nonketotic syndrome occurs in clients with type 2 diabetes. It is a condition in which the client produces enough insulin to prevent diabetic ketoacidosis but not enough to prevent severe hyperglycemia, osmotic diuresis, and extracellular fluid depletion.
A client with malignant hot nodules of the thyroid gland has a thyroidectomy. Immediately after the thyroidectomy, the nurse's priority action for this client is to: 1 Place in low-Fowler position to limit edema of the neck 2 Monitor intake and output strictly to assess for fluid overload 3 Encourage coughing and deep breathing to prevent atelectasis 4 Assess level of consciousness to determine recovery from anesthesia
1 The inflammatory response and trauma of surgery may cause edema; elevating the head facilitates drainage preventing compression of the trachea. Although monitoring intake and output strictly to assess for fluid overload is an important assessment for any postoperative client, it is not the priority for this client. Although deep breathing should be encouraged, coughing this early in the postoperative period is too traumatic to the operative site. Although assessing level of consciousness to determine recovery from anesthesia is an important assessment for any postoperative client, it is not the priority for this client.
A nurse is caring for a client after a thyroidectomy. Because of concerns about potential nerve injury associated with this type of surgery, the nurse should assess for which functional ability? 1. Speaking 2. Swallowing 3. Pursing the lips 4. Turning the head
1 The laryngeal nerve is close to the operative site and may be damaged inadvertently. Loss of the gag reflex occurs with general anesthesia; the ability to swallow signifies its return. Pursing the lips assesses the seventh cranial (facial) nerve, which is not affected by thyroid surgery. Muscles and nerves involved in turning the head are not near the thyroid gland.
When taking the blood pressure of a client who had a thyroidectomy, the nurse identifies that the client is pale and has spasms of the hand. The nurse notifies the health care provider. Which should the nurse expect the health care provider to prescribe? 1 Calcium 2 Magnesium 3 Bicarbonate 4 Potassium chloride
1 These signs may indicate calcium depletion as a result of accidental removal of parathyroid glands during thyroidectomy. Symptoms associated with hypomagnesemia include tremor, neuromuscular irritability, and confusion. Symptoms associated with metabolic acidosis include deep, rapid breathing, weakness, and disorientation. Symptoms associated with hypokalemia include muscle weakness and dysrhythmias.
he nurse provides postoperative care to the client following subtotal thyroidectomy by: Select all that apply. 1 Assessing for frequent swallowing 2 Ambulating the client the evening of surgery 3 Assessing for facial spasms, apprehension, or tingling of the lips, fingers, or toes 4 Instructing the client to support the head and maintain the neck in a flexed position 5 Ensuring that oxygen, suction equipment, and a tracheosomy tray are at the bedside
1,2,3,5 Frequent swallowing in the postoperative period following subtotal thyroidectomy may indicate hemorrhage. In the absence of complications, the client should be ambulated within a few hours following surgery. Facial spasms, apprehension, and tingling of the lips, fingers, or toes are indicative of tetany. Tetany is caused by hypocalcemia, resulting from damage to or removal of the parathyroid glands during throidectomy. Tetany is a medical emergency. Oxygen, suction equipment, and a tracheostomy tray must be kept at the bedside in case of airway edema. The bed should be placed in semi-Fowler position and the client should avoid neck flexion to prevent tension on the suture line.
While assessing a client during a routine examination, a nurse in the clinic identifies signs and symptoms of hyperthyroidism. Which signs are characteristic of hyperthyroidism? Select all that apply. 1 Diaphoresis 2 Weight loss 3 Constipation 4 Protruding eyes 5 Cold intolerance
1,2,4 Diaphoresis occurs with hyperthyroidism because of increased metabolism, resulting in hyperthermia. Weight loss occurs with hyperthyroidism because of increased metabolism. Bulging eyes occur with hyperthyroidism and are thought to be related to an autoimmune response of the retro-orbital tissue, which causes the eyeballs to enlarge and push forward. Diarrhea occurs because of increased body processes, specifically increased gastrointestinal peristalsis. Heat intolerance occurs because of the increased metabolism associated with hyperthyroidism.
A nurse teaches a client who has had a thyroidectomy for thyroid cancer to observe for signs of surgically induced hypothyroidism. What should be included in the teaching plan? Select all that apply. 1 Dry skin 2 Lethargy 3 Insomnia 4 Tachycardia 5Sensitivity to cold
1,2,5 Dry skin is a response to hypothyroidism that is related to the associated decreased metabolic rate. Lethargy and sensitivity to cold are symptoms related to hypothyroidism that are associated with a decreased metabolic rate. Insomnia and tachycardia are related to hyperthyroidism, not hypothyroidism.
A client is diagnosed with hyperthyroidism and is experiencing exophthalmia. Which measures should the nurse include when teaching this client how to manage the discomfort associated with exophthalmia? Select all that apply. 1 Use tinted glasses. 2 Use warm, moist compresses. 3 Elevate the head of the bed 45 degrees. 4 Tape eyelids shut at night if they do not close. 5 Apply a petroleum-based jelly along the lower eyelid.
1,3,4 Tinted glasses decrease light impacting on the eyes and protect eyes that are photosensitive. Elevating the head of the bed 45 degrees will promote a decrease in periorbital fluid. Taping the eyelids shut at night if they do not close reduces the risk of corneal dryness, which can lead to infection or injury. Cool, moist compresses are used to relieve irritation; warm compresses cause vasodilation, which may aggravate tissue congestion. Artificial tears are used to moisten the eyes, not a petroleum-based jelly.
A client has been taking levothyroxine (Synthroid) for hypothyroidism for three weeks. The nurse suspects that a decrease in dosage is needed when the client exhibits which clinical manifestations? Select all that apply. 1 Tremors 2 Bradycardia 3 Somnolence 4 Heat intolerance 5 Decreased blood pressure
1,4 Excessive levothyroxine produces adaptations similar to hyperthyroidism, including tremors, tachycardia, hypertension, heat intolerance, and insomnia. These adaptations are related to the increase in the metabolic rate associated with hyperthyroidism. Bradycardia is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Somnolence is a sign of hypothyroidism and a need to increase the dose of levothyroxine. Hypotension is a sign of hypothyroidism and a need to increase the dose of levothyroxine.
What length of needle is used foor vgluteal?
1.25-2.5" long (20-23 g)
What size of needle do you use for dlguteal?
18-23g, 1.25-3"
A client with a diagnosis of Graves disease refuses to have radioactive iodine (RAI) therapy, and a subtotal thyroidectomy is performed. What should the nurse do postoperatively to reduce the risk of thyroid storm? 1 Provide a high-calorie diet. 2 Prevent infection at the surgical site. 3 Encourage postoperative breathing exercises. 4 Demonstrate how to support the neck after surgery.
2 Conditions such as trauma and infection can precipitate thyroid storm (thyroid crisis, thyrotoxic crisis). A high-calorie diet does not prevent crisis; it restores glycogen reserves depleted by an increased metabolic rate. Postoperative breathing exercises prevent respiratory complications, not thyroid storm. Learning how to support the neck after surgery limits tension on the suture line, thereby decreasing the risk of hemorrhage, not thyroid storm.
A client with type 1 diabetes consistently has high glucose levels on awakening in the morning. What should the nurse instruct the client to do to differentiate between the Somogyi effect and the dawn phenomenon? 1 Eat a snack before going to bed. 2 Measure the blood glucose level between 2 AM and 4 AM. 3 Administer the prescribed bedtime insulin immediately before going to bed. 4 Identify whether symptoms experienced in the morning are associated with either hyperglycemia or hypoglycemia.
2 During the hours of sleep, the Somogyi effect may be caused by a decline in the blood glucose level in response to too much insulin. The resulting hypoglycemia stimulates counterregulatory hormones, which precipitate lipolysis, gluconeogenesis, and glycogenolysis, which in turn produce rebound hyperglycemia and ketosis. Treatment involves decreasing the evening insulin. The dawn phenomenon is characterized by the release of counterregulatory hormones in the predawn hours, precipitating hyperglycemia on awakening. Treatment involves an increase in insulin. Eating a snack before going to bed should be done when insulin is taken before sleep, but it will not help to differentiate between the Somogyi effect and the dawn phenomenon. Administering the prescribed bedtime insulin immediately before going to bed depends on the insulin regimen prescribed by the health care provider and will not help to differentiate between the Somogyi effect and the dawn phenomenon. Both the Somogyi effect and the dawn phenomenon are characterized by hyperglycemia, not hypoglycemia.
One week after beginning antithyroid medication for the treatment of hyperthyroidism, a client reports diarrhea, abdominal pain, and a fever. The client is admitted with a diagnosis of thyrotoxic crisis. The nurse determines that the most important intervention for this client is: 1 Limiting fluid intake 2 Reducing body temperature and heart rate 3 Observing for an exaggerated response to sedatives 4 Treating the associated hyperglycemia and ketoacidosis
2 Immediate treatment in this emergency focuses on reduction of oxygen demands and thus cardiac workload to prevent cardiac decompensation. The need is for an increase, not decrease, in fluid intake to compensate for that lost because of the high metabolic rate. A response to sedatives is not likely because drugs are metabolized more rapidly with thyrotoxic crisis; there is a danger of exaggerated effects of the drug with hypothyroidism. Clients with thyrotoxic crisis are more apt to develop hypoglycemia from the high metabolic rate.
A client with hyperthyroidism is treated with radioactive iodine to ablate thyroid tissue. What should the nurse instruct the client to do after the procedure? 1.Remain in the house. 2. Avoid holding an infant. 3. Save urine in a lead-lined container. 4. Refrain from using a bathroom used by others
2 Infants are particularly sensitive to radioactivity; even the small amount emitted after treatment may affect infants. It is not necessary to avoid leaving the house as long as close proximity to others is avoided. Saving urine in a lead-lined container is not necessary; the same bathroom may be used by all members of the family, but the toilet should be flushed twice after use by the client. Refraining from using a bathroom used by others is not necessary.
A nurse is caring for a postoperative client who has diabetes. Which is the most common cause of diabetic ketoacidosis that the nurse needs to consider when caring for this client? 1 Emotional stress 2 Presence of infection 3 Increased insulin dose 4 Inadequate food intake
2 Infection increases the body's metabolic rate, and insulin is not available for increased demands. Although emotional stress will affect glucose levels, diabetic ketoacidosis will rarely result. Increased insulin dose will lead to insulin coma (hypoglycemia) if diet is not increased as well. Inadequate food intake will result in insulin coma.
A nurse is caring for a client with a diagnosis of type 1 diabetes who has developed diabetic coma. Which element excessively accumulates in the blood to precipitate the signs and symptoms associated with this condition? 1 Sodium bicarbonate, causing alkalosis 2 Ketones as a result of rapid fat breakdown, causing acidosis 3 Nitrogen from protein catabolism, causing ammonia intoxication 4 Glucose from rapid carbohydrate metabolism, causing drowsiness
2 Ketones are produced when fat is broken down for energy. Although rarely used, sodium bicarbonate may be administered to correct the acid-base imbalance resulting from ketoacidosis; acidosis is caused by excess acid, not excess base bicarbonate. Diabetes does not interfere with removal of nitrogenous wastes. Carbohydrate metabolism is impaired in the client with diabetes.
Which nursing intervention is most appropriate for a client in skeletal traction? 1 Add and remove weights as the client desires. 2 Assess the pin sites at least every shift and as needed. 3 Ensure that the knots in the rope are tied to the pulley. 4 Perform range of motion to joints proximal and distal to the fracture at least once a day.
2 Nursing care for a client in skeletal traction may include assessing pin sites every shift and as needed. The needed weight for a client in skeletal traction is prescribed by the physician not as desired by the client. The nurse also should ensure that the knots are not tied to the pulley and move freely. The performance of range of motion is indicated for all joints except the ones proximal and distal to the fracture, since this area is immobilized by the skeletal traction to promote healing and prevent further injury and pain.
A client with newly diagnosed hyperthyroidism is treated with propylthiouracil (PTU), an antithyroid drug, along with potassium iodide. What should the nurse take into consideration when caring for the client? 1 Iodide solutions must be diluted in water and taken on an empty stomach. 2 Monitoring for signs of infection or bleeding is necessary. 3 Postoperative hemorrhage is a common complication if these drugs are used before a thyroidectomy. 4 These drugs will be discontinued as soon as the temperature and pulse rate return to the expected range.
2 PTU can cause depression of leukocytes and platelets. Propylthiouracil and potassium iodide should be given with milk, juice, or food to prevent gastric irritation. Drug therapy decreases the risk of postoperative hemorrhage because this drug regimen decreases the size and vascularity of the thyroid gland. Drug therapy is continued for at least six to eight weeks, even if the client's temperature and pulse return to the expected range.
A client with type 1 diabetes is diagnosed with diabetic ketoacidosis and initially treated with intravenous (IV) fluids followed by an IV bolus of regular insulin. The nurse anticipates that the health care provider will prescribe a continuous infusion of: 1 Novolin L insulin. Novolin R insulin. 3 Novolin N insulin. 4 Novolin U insulin.
2 Regular insulin is the only insulin that is administered intravenously. Novolin L insulin cannot be administered intravenously. Novolin N insulin cannot be administered intravenously. Novolin U insulin cannot be administered intravenously.
When a nurse plans to teach a client with type 1 diabetes about the use of an insulin pump, it is of major importance that the client understand that the: 1. Insulin pump's needle should be changed every day 2. Pump is an attempt to mimic the way a healthy pancreas works 3. Pump will be implanted in a subcutaneous pocket near the abdomen 4. Insulin pump's advantage is that it requires glucose monitoring once a day
2 The basal infusion rate mimics the low rate of insulin secretion during fasting, and the bolus before meals mimics the high output after meals. The subcutaneous needle may be left in place for as long as three days. Most insulin pumps are external to the body and access the body via a subcutaneous needle. Blood glucose monitoring is done a minimum of four times a day.
After a thyroidectomy, the client exhibits carpopedal spasm and some tremors. The client reports a sensation of tingling in the fingers and around the mouth. What medication should the nurse expect the health care provider to prescribe? 1 Potassium iodide 2 Calcium gluconate 3 Magnesium sulfate 4 Potassium chloride
2 The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroids; calcium gluconate is the treatment of choice. Potassium iodide is prescribed for hyperthyroidism because it inhibits the release of thyroidhormones. The client is exhibiting signs and symptoms of hypocalcemia, which occurs with accidental removal of the parathyroids; calcium gluconate is the treatment of choice. Magnesium sulfate is prescribed for hypomagnesemia or to prevent convulsions in eclampsia or preeclampsia. Potassium chloride is prescribed for hypokalemia.
A health care provider prescribes propylthiouracil (PTU) for a client with hyperthyroidism. Two months after being started on the antithyroid medication, the client calls the nurse and complains of feeling tired and looking pale. What should the nurse do? 1. Advise the client to get more rest. 2.Schedule the client for an appointment. 3. Instruct the client to skip one dose daily. 4. Tell the client to increase the medication.
2 The client should be examined by the health care provider and blood tests prescribed; anemia may result because of the bone marrow depressant effect of PTU. Advising the client to get more rest is unsafe advice; a physical examination and blood tests are necessary to determine the cause of the client's fatigue and paleness. It is unsafe to skip one dose of PTU daily without a health care provider's prescription; advising the client to alter the dosage of a drug is not within the legal role of the nurse. It is unsafe to increase the dose of PTU without a health care provider's prescription; advising the client to alter the dosage of a drug is not within the legal role of the nurse.
A client who had a subtotal thyroidectomy returns to the unit from the postanesthesia care unit. What is the priority nursing action at this time? 1 Monitor for hypoglycemia. 2 Observe for signs of tetany. 3 Place a sandbag under the neck. 4 Teach the need to support the head.
2 The parathyroids may be excised accidentally during surgery; because they regulate calcium, lowered blood levels of calcium may induce tetany. There is no danger of hypoglycemia at this time. A sandbag under the neck can cause hyperextension and strain on the suture line. Teaching the need to support the head is not the priority at this time, although it is important to prevent tension on the suture line.
A nurse teaches a client with type 1 diabetes about the treatment of hypoglycemia. If the teaching is effective, which foods does the client identify to manage hypoglycemia? 1 Hard candy and fruit juice 2 Cheese sandwich and sugar 3 Chocolate candy and an orange 4 Peanut butter crackers and a glass of milk
2 The suggested treatment for hypoglycemia is to give a conscious client a simple sugar (e.g., two packets of sugar) followed by a complex carbohydrate (e.g., bread) and protein (e.g., cheese); the simple sugar elevates blood glucose rapidly; the complex carbohydrate and protein produce a more sustained response. Hard candy and fruit juice are fast-acting sugars that will increase blood glucose rapidly; neither provides a sustained response. Chocolate candy and an orange are fast-acting sugars that will increase blood glucose rapidly; neither provides a sustained response. Neither peanut butter crackers nor a glass of milk are fast-acting sugars; peanut butter crackers and milk can be used to maintain the glucose level after it has been raised.
A client with hyperthyroidism has been treated with radioactive iodine (131I) to destroy overactive thyroid gland cells. To reduce radiation exposure, the nurse's principles for providing care should be based on: 1. Wearing a lead-shield apron at all times 2. Limiting distance and time spent with the client 3. Wearing a radiation meter to measure exposure 4. Remaining at least 6 feet away from the client at all times
2 When caring for clients who are radioactive, the three most important concepts for reducing radiation exposure are to limit exposure time, increase distance, and use shielding. In this situation, time and distance provide the best reduction in radiation exposure. Wearing a lead-shield apron will help prevent radiation exposure, but time and distance are the first priorities. A radiation meter measures exposure but does nothing to protect caretakers. Remaining at least 6 feet away from the client at all times is not a practical approach.
A client with diabetes mellitus complains of difficulty seeing. The nurse concludes that the causative factor is: 1 Lack of glucose in the retina 2 Neovascularization of the retina 3 Inadequate glucose supply to rods and cones 4 Destructive effect of ketones on retinal metabolism
2 With diabetes mellitus, proliferation of fragile vessels and progressive thickening of the capillary basement membranes lead to decreased retinal perfusion and hemorrhages in the eye. Hemorrhages in the eyes precipitate retinal detachment, resulting in blindness. There is an increase in serum glucose in clients with diabetes mellitus; thickening of the capillary basement membranes can occur, even if the glucose level is maintained within normal limits. Ketones do not affect retinal metabolism; retinopathy is a result of vascular changes, retinal detachment, and hemorrhage within the eye.
The nurse concludes that a client with type 1 diabetes is experiencing hypoglycemia. Which responses support this conclusion? Select all that apply. 1 Vomiting 2 Headache 3 Tachycardia 4 Cool clammy skin 5 Increased respirations
2,3,4 Headache is a neuroglycopenic response directly related to brain glucose deprivation. Tachycardia occurs with hypoglycemia because of a neurogenic adrenergic response; it is a sympathetic nervous system response precipitated by a low blood glucose level. Cool, clammy skin is a neurogenic cholinergic response; it is a sympathetic nervous system response precipitated by a low serum glucose level. Vomiting occurs with hyperglycemia because of the effects of metabolic acidosis. Increased respirations are a sign of hyperglycemia and are related to metabolic acidosis; this is a compensatory response in an attempt to blow off carbon dioxide and increase the pH level.
What clinical indicators should a nurse expect when assessing a client with hyperthyroidism? Select all that apply. 1 Dry skin 2 Weight loss 3 Tachycardia 4 Restlessness 5 Constipation 6 Exophthalmos
2,3,4,6 Weight loss is associated with hyperthyroidism because of the increase in the metabolic rate. Muscle weakness and wasting also occur. Tachycardia, palpitations, increased systolic blood pressure, and dysrhythmias occur with hyperthyroidism because of the increased metabolic rate. Restlessness and insomnia are also associated with hyperthyroidism because of the increased metabolic rate. Protrusion of the eyeballs occurs with hyperthyroidism because of peribulbar edema. Dry, coarse, scaly skin occurs with hypothyroidism, not hyperthyroidism, because of decreased glandular function. Smooth, warm, moist skin occurs with hyperthyroidism. Constipation is associated with hypothyroidism. Increased stools and diarrhea are associated with hyperthyroidism.
Which clinical findings should the nurse expect when assessing a client with hyperthyroidism? Select all that apply. 1 Lethargy 2 Tachycardia 3 Weight gain 4 Constipation 5 Exophthalmos
2,5 Tachycardia is associated with hyperthyroidism and is caused by the increase in the basal metabolic rate. Exophthalmos is associated with hyperthyroidism and results from accumulation of fluid behind the eyeball. Lethargy is associated with hypothyroidism; hyperactivity occurs with hyperthyroidism. Weight gain occurs with hypothyroidism; weight loss occurs with hyperthyroidism because of the high metabolic rate. Constipation is associated with hypothyroidism; frequent loose stools occur with hyperthyroidism.
What size of needle is used in IM injections?
20-23 g, (18 g for blood products) usually 1- 1 1/2" long (1-3mL syringe)
A client who had a subtotal thyroidectomy asks how hypothyroidism may develop when the problem was hyperthyroidism. What should the nurse consider when formulating a response? 1.Hypothyroidism is a gradual slowing of the body's function. 2A decrease in pituitary thyroid-stimulating hormone (TSH) will occur. 3.Less thyroid tissue is available to supply thyroid hormone after surgery. 4. Atrophy of tissue remaining after surgery reduces secretion of thyroid hormones
3 After a thyroidectomy, thyroxine output usually is inadequate to maintain an appropriate metabolic rate. Hypothyroidism is decreased thyroid functioning, not a slowing of functions of the entire body. With hypothyroidism, the level of TSH from the pituitary usually is increased. Thyroid tissue remaining after surgery does not atrophy.
A nurse is caring for a newly admitted client with a diagnosis of Cushing syndrome. Why should the nurse monitor this client for clinical indicators of diabetes mellitus? 1 Cortical hormones stimulate rapid weight loss. 2 Tissue catabolism results in a negative nitrogen balance. 3 Glucocorticoids accelerate the process of gluco-neogenesis. 4 Excessive adrenocorticotropic hormone (ACTH) secretion damages pancreatic tissue.
3 Excess glucocorticoids cause hyperglycemia, and signs of diabetes mellitus may develop ACTH causes sodium retention and subsequent weight gain. Although muscle wasting is associated with excessive corticoid production, this will not cause diabetes mellitus. ACTH affects the adrenal cortex, not the pancreas.
Which factor identified by the nurse while obtaining the client's health history predisposes a client to type 2 diabetes? 1 Having diabetes insipidus 2 Eating low-cholesterol foods 3Being twenty pounds overweight 4Drinking a daily alcoholic beverage
3 Excessive body weight is a known predisposing factor to type 2 diabetes; the exact relationship is unknown. Diabetes insipidus is caused by too little antidiuretic hormone (ADH) and has no relationship to type 2 diabetes. High-cholesterol diets and atherosclerotic heart disease are associated with type 2 diabetes. Alcohol intake is not known to predispose a person to type 2 diabetes.
A client newly diagnosed as having type 1 diabetes is taught to exercise on a regular basis primarily because exercise has been shown to: 1 Decrease insulin sensitivity 2 Stimulate glucagon production 3 Improve the cellular uptake of glucose 4 Reduce metabolic requirements for glucose
3 Exercise increases the metabolic rate, and glucose is needed for cellular metabolism; therefore, excess glucose is consumed during exercise. Regular vigorous exercise increases cell sensitivity to insulin. Glucagon action raises blood glucose but does not affect cell uptake or use of glucose. Cellular requirements for glucose increase with exercise.
A client who is feeling increasingly tired seeks medical care. Type 1 diabetes is diagnosed. The nurse explains that the increased fatigue is the result of: 1 Increased metabolism at the cellular level 2 Increased glucose absorption from the intestine 3 Decreased production of insulin by the pancreas 4 Decreased glucose secretion into the renal tubules
3 Insulin facilitates transport of glucose across the cell membrane to meet metabolic needs and prevent fatigue. With diabetes there is decreased cellular metabolism because of the decrease in glucose entering the cells. Glucose is not absorbed from the intestinal tract by the cells; fatigue is caused by decreased, not increased, cellular levels of glucose. Filtration and excretion of glucose by the kidneys do not regulate energy levels; if insulin production is adequate, glucose does not spill into the urine.
A 40-year-old male is prescribed Metformin XL (Glucophage) to control his type 2 diabetes mellitus. Which statement made by this client indicates the need for further education? 1 "I will take the drug with food." 2 "I must swallow my medication whole and not crush or chew it." 3 "I will stop taking Metformin for 24 hours before and after having a test involving dye." 4 "I will notify my doctor if I develop muscular or abdominal discomfort."
3 Metformin must be withheld for 48 hours before the use of iodinated contrast materials to prevent lactic acidosis. Metformin is restarted when kidney function has returned to normal. Metformin is taken with food to avoid adverse gastrointestinal effects. If crushed or chewed, Metformin XL will be released too rapidly and may lead to hypoglycemia. Muscular and abdominal discomfort is a potential sign of lactic acidosis and must be reported to the health care provider.
On the first day after a thyroidectomy, a client tolerates a full-liquid/fluid diet. When the diet is progressed to a soft diet the next day, the client complains of a sore throat when swallowing. How should the nurse respond? 1 Place the client on a full liquid/fluid diet to prevent choking 2 Notify the health care provider immediately 3Administer prescribed analgesics before meals 4Assist the client to gargle with saline to moisten mucous membranes
3 Soreness when swallowing is to be expected; a progression to a soft diet will provide nutrients needed for healing and energy and will stimulate the return of bowel activity; analgesics as prescribed will reduce pain during meals. It is unnecessary to reverse the progression of the diet back to the full-liquid diet. Discomfort when swallowing is expected after a thyroidectomy. Although it may be uncomfortable to swallow, the client is not choking and is able to manage safely the consistency of the diet. If necessary, a nurse can always decrease the consistency of a prescribed diet if the consistency cannot be managed safely by the client, and then notify the health care provider. Soreness when swallowing is to be expected; this is not an emergency necessitating medical action. The soreness is not because of drying; humidified air might help reduce soreness, but it will not help the client eat the soft diet.
A client is scheduled to have a thyroidectomy for cancer of the thyroid. What specific instruction about postoperative care should the nurse provide the client during preoperative teaching? 1 Cough and deep breathe every hour. 2 Perform range-of-motion exercises of the head and neck. 3 Support the head with the hands when changing position. 4 Apply gentle pressure against the incision when swallowing.
3 Supporting the head with the hands when changing position relieves tension on the incision and limits the risk of dehiscence. Coughing should be avoided during the early postoperative period to prevent trauma to the operative site. Performing range-of-motion exercises of the head and neck should be avoided until advised by the health care provider, usually after sutures or skin clips have been removed. Pressure against the operative area is not necessary to promote integrity of the incision, and it may inhibit swallowing.
Four hours after surgery the blood glucose level of a client who has type 1 diabetes is elevated. The nurse can expect to: 1 Administer an oral hypoglycemic 2 Institute urine glucose monitoring 3 Give supplemental doses of regular insulin 4 Decrease the rate of the intravenous infusion
3 The blood glucose level needs to be reduced; regular insulin begins to act in 30 to 60 minutes. The client has type 1, not type 2, diabetes, and an oral hypoglycemic will not be effective. Blood glucose levels are far more accurate than urine glucose levels. The rate may be increased because polyuria often accompanies hyperglycemia.
A client with type 2 diabetes is admitted for elective surgery. The health care provider prescribes regular insulin even though oral antidiabetics were adequate before the client's hospitalization. The nurse concludes that regular insulin is needed because the: 1 Client will need a higher serum glucose level while on bed rest. 2 Possibility of acidosis is greater when a client is on oral hypoglycemics. 3 Dosage can be adjusted to changing needs during recovery from surgery. 4 Stress of surgery may precipitate uncontrollable periods of hypoglycemia.
3 There is better control of blood glucose levels with short-acting (regular) insulin. The level of glucose must be maintained as close to normal as possible. The occurrence of acidosis is greater when the client is receiving exogenous insulin. The stress of surgery will precipitate hyperglycemia, which is best controlled with exogenous insulin.
nurse is caring for a client with a history of hyperthyroidism who now is experiencing thyroid crisis (thyroid storm). What does the nurse consider to be the most likely precipitating factor in the client's current health problem? 1 Increased iodine in the blood 2 Removal of the parathyroid glands 3 High levels of the hormone triiodothyronine 4 Rebound increase in metabolism following anesthesia
3 Thyroid trauma, thyroid surgery, or physiological stress in a client with hyperthyroidism may lead to a release of abnormally high levels of thyroid hormones. High levels of the hormone triiodothyronine intensifies all the signs and symptoms of hyperthyroidism (thyroid storm or crisis), such as increased temperature, pulse, and respirations, restlessness, vomiting, and often death. Iodine binds with thyroxine, thus decreasing the potential for crisis. Tetany, not thyroid crisis, occurs from surgical excision of the parathyroid glands. Anesthesia will depress metabolism, not increase it.
A client with type 2 diabetes develops gout, and allopurinol (Zyloprim) is prescribed. The client is also taking metformin (Glucophage) and an over-the-counter nonsteroidal antiinflammatory drug (NSAID). When teaching about the administration of allopurinol, what should the nurse instruct the client to do? 1 Decrease the daily dose of NSAIDs. 2 Limit fluid intake to one quart a day. 3 Take the medication on an empty stomach. 4 Monitor blood glucose levels more frequently.
4 Allopurinol can potentiate the effect of oral hypoglycemics, causing hypoglycemia; the blood glucose level should be monitored more frequently. NSAIDs can be taken concurrently with Allopurinol. A daily fluid intake of 2500 to 3000 mL will limit the risk of developing renal calculi. Allopurinol should be taken with milk or food to decrease gastrointestinal irritation.
A client with diabetes who is receiving long-term corticosteroid therapy is admitted to the hospital with leg ulcers. What should the nurse expect to identify when assessing this client? 1 Weight loss 2 Hypoglycemia 3 Decreased blood pressure 4 Inadequate wound healing
4 Because the antiinflammatory response is depressed as a result of increased cortisol levels, the wounds of clients receiving long-term corticosteroid therapy tend to heal slowly. A common finding associated with long-term corticosteroid use is weight gain, caused not only by fluid retention, but also alterations in fat, carbohydrate (CHO), and protein metabolism. Persistent hyperglycemia (steroid diabetes) occurs because of altered glucose metabolism. Hypertension, not hypotension, occurs as a result of sodium and fluid retention.
The nurse is caring for a client with type 1 diabetes who is developing ketoacidosis. Which arterial blood gas report is indicative of diabetic ketoacidosis? 1 PCO2 49, HCO3 32, pH 7.50 2 PCO2 26, HCO3 20, pH 7.52 3 PCO2 54, HCO3 28, pH 7.30 4 PCO2 28, HCO3 18, pH 7.28
4 Decreased pH and bicarbonate values reflect metabolic acidosis; a decreased PCO2 value indicates compensatory hyperventilation. Increased pH and bicarbonate values reflect metabolic alkalosis; an increased PCO2 value indicates compensatory hypoventilation. Increased pH and decreased PCO2 values reflect hyperventilation and respiratory alkalosis. Decreased pH and increased PCO2 values reflect hypoventilation and respiratory acidosis.
A client with hyperthyroidism refuses radioactive iodine therapy and a subtotal thyroidectomy is scheduled. The nurse reviews the preoperative plan of care and questions which prescription? 1 High-protein, high-carbohydrate diet 2 Iodine preparations 3 Antithyroid drugs 4 Drugs to increase the blood pressure
4 Having a normally functioning thyroid (euthyroid) decreases the risk of thyrotoxic crisis after surgery. Ideally the client should be normotensive; some clients are slightly hypertensive because of the increased metabolic rate associated with hyperthyroidism. Weighing in the expected range may be impossible; the client may be underweight because of the increased metabolic rate associated with hyperthyroidism. The client should be in a positive nitrogen balance to promote wound healing.
client with type 1 diabetes who has been adhering to a prescribed insulin regimen is admitted to the hospital in ketoacidosis. Which factor may have precipitated the ketoacidosis? 1 Increased exercise 2 Decreased food intake 3 Working the night shift 4 Upper respiratory infection
4 Infection is a stress that increases adrenocortical secretion of glucocorticoids, which will increase the blood glucose level. Exercise requires glucose for muscle contraction, which decreases the blood glucose level. Decreased food intake will decrease the blood glucose level. Working the night shift will have no impact on the blood glucose level.
A client is admitted to the hospital with the diagnosis of cancer of the thyroid and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period? 1 Hypercalcemia may result from parathyroid damage. 2 Hypotension and bradycardia may result from thyroid storm. 3 Tetany may result from underdosage of thyroid hormone replacement. 4 Hoarseness and airway obstruction may result from laryngeal nerve damage.
4 Laryngeal nerve injury can cause laryngeal spasms, resulting in airway obstruction. Parathyroid damage results in hypocalcemia, not hypercalcemia. Thyroid storm (thyroid crisis) is characterized by the release of excessive levels of thyroid hormone, which increases the metabolic rate. An increase in the metabolic rate increases vital signs, resulting in hypertension, not hypotension, and tachycardia, not bradycardia. Tetany is caused by a decrease in parathormone, a parathyroid hormone, not a thyroid hormone.
The nurse is caring for a client with diabetes mellitus that is scheduled to receive an intravenous (IV) administration of 25 units of insulin in 250 mL normal saline. The only type of insulin that is compatible with intravenous solutions is: 1. Lispro (Humalog) insulin 2. Glargine (Lantus) insulin 3. Novolin N insulin 4. Novolin R insulin
4 Novolin R insulin acts rapidly and is compatible with intravenous solutions. Lispro insulin is not compatible with intravenous solutions; it is a rapid-acting insulin. Glargine insulin is not compatible with intravenous solutions; it is a long-acting insulin. Novolin N insulin is not compatible with intravenous solutions; it is an intermediate-acting insulin.
A nurse is reviewing the diagnostic blood tests of a client with a diagnosis of type 1 diabetes. Which laboratory results support the nurse's suspicion that the client is experiencing ketoacidosis? 1 Blood glucose of 40 mg/100 mL, blood pH of 7.37 2 Blood glucose of 130 mg/100 mL, blood pH of 7.35 3 Blood glucose of 650 mg/100 mL, blood pH of 7.42 4 Blood glucose of 300 mg/100 mL, blood pH of 7.20
4 The blood glucose level of 300 mg/100 mL is above the expected range of individuals with type 1 diabetes, indicating hyperglycemia . The normal serum pH is 7.35 to 7.45; therefore, 7.20 indicates acidosis. The blood glucose level of 40 mg/100 mL is below the expected range for all individuals, indicating hypoglycemia; the serum pH of 7.37 is within the expected range for pH. The blood glucose level of 130 mg/100 mL is within the expected range for individuals with type 1 diabetes and the pH of 7.35 is within the expected range for pH. The blood glucose level of 650 mg/100 mL indicates hyperglycemia but the serum pH is within the expected range for pH.
A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? Select all that apply. 1 Dry skin 2 Slow pulse 3 Weight gain 4 Nervousness 5 Increased appetite
4,5 Nervousness is associated with hyperthyroidism because of central nervous system irritation. The appetite increases with hyperthyroidism because of the increase in the metabolic rate. Moist skin occurs with hyperthyroidism because of the increase in the metabolic rate. Dry skin occurs with hypothyroidism because of the decrease in the metabolic rate. Tachycardia occurs with hyperthyroidism because of the increase in the metabolic rate. Bradycardia occurs with hypothyroidism because of the decrease in the metabolic rate. Weight loss occurs with hyperthyroidism because of the increase in the metabolic rate. Weight gain occurs with hypothyroidism because of the decrease in the metabolic rate.
What size of needle is needed for the vastus lateralis site?
5/8-1"
Where are subQ sites?
Abdomen, upper hips, upper back, lateral upper arms, lateral thigh
Why are the locations chosen for IM injections?
Adequate muscle and minimal major nerves and blood vessels
What are the advantages of the VL injection site?
Area good for many injections, free of major nerves; however, if the needle is too long it will hit the sciatic nerves..
Why are subQ sites chosen?
Because of the adequate fat pad sites
How do you insert the needle on the intradermal route?
Bevel up, 10-15* (*=degree), the outline of the needle should be visible beneath the skin and inject slowly
What must you do if (more than) <1 ml of meds are to be injected into the body with subQ injections?
Change needles and sites
How do you locate the right placement for dgluteal?
Draw an imaginarry line between post. Illiac spine and greater trochanter. The right spot is midpoint and above this line.
What do you do after you inject a SubQ injection, and what are two injections?
Gently massage it: (not with heparin and LMWH) *Another example is insulin. apply gentle pressure to reduce bleeding or ooozing and bruising. You do want pressure after heparin to reduce tissue damage.
When do you NOT aspirate with subQ injections?
Heparin, LMWH, insulin (jess: "surly pirates have parrots and suck on limes..." SUrly=subQ, asPIRATE=PIRATEs, PARrots=hePARin, suck=inSUlin, limes=LMwh)
Which intervention will the nurse plan when administering a medication subcutaneously?
Insert the needle at a 45-90* angle, depending on client size, to penetrate subcutaneous tissue. The proper technique for subcutaneous injections involves the use of a 5/8" needle, 25-27g, @ a 45-90* angle of insertion, dependent on client size. 1- 1-½ inch needle is used for IM injection. Aspiration is done with all medications EXCEPT anticoagulants and insulin. The landmark for the vastus lateralis is one handbreadth below the greater trochanter and above the knee on the outer aspect of the thigh.
Why is subQ injections used over other routes?
It has a sustained effect, is absorbed through the capillaries, it has a slower absorption than IM.
What is an advantage of the deltoid injections?
It is easily accessible and pt can be in any position
What is an advantage of subQ injections?
It is non irritating
Sub Q Sites
Locations for SubQ sites are chosen for adequate fat-pad size and include: -the abdomen, -upper hips, -upper back, -lateral upper arms, and -lateral thighs (*Sites should be rotated with SubQ injections such as insulin and heparin.
What is enteral route? (6 things)
Oral, eye drops, ear drops, inhalation, suppositories, topicals (jess: head, shoulders, knees, and toes... Eyes, ears, mouth, and nose.)
What must you do to the skin on a subQ injections?
Pinch it
How do you insert an IV?
Place tourniquet above the selected vein, insert a needle into vein bevel up and short angle to skin (10--15*), if the needle is inserted properly there should be a backflow (FYI: As an uncertified LPN, you can't without IV therapy class)
What position do you put the patient in for dgluteal?
Prone
What must you do before taking out the needle on subQ injections?
Release the skin
At what angle should you insert the needle on an vgluteal?
Slightly angled towards the iliac crest (*pg 43 of text)
How fast do you inject subQ injections?
Slowly
How can a drug be given through an IV? (4)
Slowly or rapidly Piggyback into an existing IV bag Into a heparin/saline lock
What types of medications are used for subQ injections?
Small doses of non irritating, water-soluable drugs
What is the preferred IM site?
Ventrogluteal
The nurse administers iron dextran to the client. What special considerations are associated with this? (select all that apply) a) Gluteal site is preffered, best with different needle to draw up and administer b) Deltoid site is preferred, increased chance of "self sticks" c) Vastus lateralis site is preferred d) Gluteal site is preferred with use of one needle
a) Gluteal site is preffered, best with different needle to draw up and administer
The clinic nurse administers a TB test to the client. Which supplies are best used? a) 21 gauge, 5/8 inch needle b) 27 gauge, 5/8 inch needle, 3 mL syringe c) 25 gauge needle, insulin syringe d) 25 gauge needle, tuberculin syringe
d) 25 gauge needle, tuberculin syringe
How much syrum is INJECTED during the intradermal route
usually 0.01-0.1 ml injected -->(Syringe= 1mL calibrated to 0.01 mL increments)
A nurse is caring for a client who just returned from the postanesthesia care unit after having a thyroidectomy. Which action has priority during the first 24 hours after surgery when the nurse is concerned about thyroid storm? 1 Performing range-of-motion exercises 2 Humidifying the room air continuously 3 Assessing for hoarseness every two hours 4 Checking vital signs every two hours after they stabilize
4 Checking vital signs helps detect complications such as thyrotoxic crisis, hemorrhage, and respiratory obstruction that may occur early in the postoperative period. Range-of-motion exercises should not begin until two to four days postoperatively because they can disrupt the suture line. A humidifier can contribute to the spread of bacteria and infection and is contraindicated. Hoarseness and voice weakness usually are temporary and not life threatening; the priority is to observe for thyroid storm, hemorrhage, and respiratory obstruction.
After treatment with propylthiouracil for hyperthyroidism, a client has the thyroid ablated with 131I. On a visit to the endocrine clinic, the client exhibits signs and symptoms of thyrotoxic crisis (thyroid storm). The nurse recalls that what is often associated with thyrotoxic crisis? 1 Deficiency of iodine 2 Decreased serum calcium 3 Increased sodium retention 4 Excessive hormone replacemen
4 Thyrotoxic crisis (thyroid storm) is the body's response to excessive circulating thyroid hormones. A deficiency of iodine results in a deficiency in thyroid hormone production. A decreased serum calcium causes tetany. Sodium retention is unrelated to thyrotoxic crisis; thyrotoxic crisis is caused by excessive circulating thyroid hormones.
Why is the intradermal used and what tests are they used for?
Absorbs slowly, for sensitivity tests, tb, immunotherapy for cancer and local anesthetic.
What size of needle is used for the deltoid site?
23-25g, 5/8-1.5" long
A client is scheduled for a subtotal thyroidectomy. What equipment is most important for the nurse to have available when preparing for the client's return from surgery? 1 Sandbags 2 Hemostats 3 Tracheotomy tray 4 Nasogastric suction
3 The possibility of respiratory complications caused by edema of the glottis or injury to the recurrent laryngeal nerve may require a tracheotomy. Sandbags are not necessary because the client may move the head when the neck is supported. Hemostats are not kept at the bedside; if hemorrhage occurs, it most likely will be internal, and the vessel cannot be clamped. Nasogastric suction usually is not necessary; clients rarely have a nasogastric tube.
Which landmarks does the nurse plan to use when administering an IM injection into the dgluteal region?
c. Anterior to the diagonal line from the greater trochanter to the posterior superior iliac spine. The correct anatomic landmarks for the dgluteal site are found by finding the greater trochanter and the posterior superior iliac crest and drawing a line between the two. The injection is then administered above that line.
A nurse is monitoring a client's fasting plasma glucose (FPG) level. At which FPG level should the nurse identify that the client has prediabetes? 1 70 mg/dL 2 100 mg/dL 3 130 mg/dL 4 160 mg/dL
2 The guidelines from the American Diabetes Association have lowered the level of an FPG that indicates whether a client has prediabetes from 110 mg/dL to 100 mg/dL; an FPG of 100 to 125 mg/dL is considered prediabetes. A 70 mg/dL FPG indicates that the client is hypoglycemic. An FPG of 126 mg/dL or higher indicates that the client has diabetes.
A client visits the clinic because of concerns about insomnia and recent weight loss. A tentative diagnosis of hyperthyroidism is made. In addition to these changes, the nurse further assesses this client for: 1 Fatigue 2 Dry skin 3 Anorexia 4 Bradycardia
1 Excessive metabolic activity associated with hyperthyroidism causes fatigue. Warm, moist skin is expected because of increased peripheral perfusion associated with increased metabolism. Increased appetite is expected because of the increased metabolism associated with hyperthyroidism. Tachycardia is expected because of the increased metabolism associated with hyperthyroidism.
What type of needle do you use for subQ injection?
25-27 g, 1/2-5/8" long (Volume= 0.5-1.5mL injected using a 1-3mL syringe)
When assessing a client with Grave's disease (hyperthyroidism) the nurse expects to identify a history of: 1 Diaphoresis 2 Menorrhagia 3 Dry, brittle hair 4 Sensitivity to cold
1 Increased basal metabolic rate, increased circulation, and vasodilation result in warm, moist skin. Menorrhagia, dry, brittle hair, and sensitivity to cold are associated with hypothyroidism.
The nurse is assessing a client with hyperthyroidism. For which signs and symptoms should the nurse assess the client? Select all that apply. 1. Amenorrhea 2. Hypotension 3. Facial edema 4. Flushed appearance 5. Short attention span
1,4,5 Amenorrhea is due to hypothalamic or pituitary disturbances associated with hyperthyroidism. The skin is warm and flushed because of a hyperdynamic circulatory state. A short attention span is related to altered cerebral metabolism from excess thyroid hormones. Hypertension is associated with hyperthyroidism; hypotension is associated with hypothyroidism. Facial edema is not related to hyperthyroidism. Hypothyroidism is associated with decreased renal blood flow that results in fluid retention (e.g., peripheral and facial edema).
A nurse evaluates that a client with diabetes understands the teaching about the treatment of hypoglycemia when the client says, "If I become hypoglycemic I initially should eat: 1 Fruit juice and a lollipop." 2 Sugar and a slice of bread." 3 Chocolate candy and a banana." 4 Peanut butter crackers and a glass of milk."
2 The suggested treatment of hypoglycemia in a conscious client is a simple sugar (such as two packets of sugar), followed by a complex carbohydrate (such as a slice of bread), and finally a protein (such as milk); the simple sugar elevates the blood glucose level rapidly; the complex carbohydrates and protein produce a more sustained response. Fruit juice and a lollipop are fast-acting sugars, and neither of them will provide a sustained response. The fat content of chocolate candy decreases the rate of absorption of glucose. Neither peanut butter crackers or a glass of milk are a fast-acting sugar; peanut butter crackers and milk can be used to maintain the glucose level after it is raised.
A client with cancer of the thyroid is scheduled for a thyroidectomy. What should the nurse teach the client? 1 The dietary intake of carbohydrates must be restricted. 2 Chemotherapy may be used in conjunction with the surgery. 3 Thyroxine replacement therapy will be required indefinitely. 4 A tracheostomy requires an alternate means of communication.
3 Thyroxine is given postoperatively to suppress thyroid-stimulating hormone (TSH) and prevent hypothyroidism. Increased intake of carbohydrates and proteins is needed because of the increased metabolic activity associated with hyperthyroidism. Chemotherapy is uncommon; radiation may be used to eradicate remaining tissue. A tracheostomy is not planned; it is needed only in an emergency related to respiratory distress.
client with type 1 diabetes asks, "Why can't I take insulin by mouth? I have a cousin with diabetes who takes pills." On which fact should the nurse base a response? 1 The cousin probably does not have diabetes. 2 Oral hypoglycemics predispose diabetic clients to lipodystrophy. 3 Insulin taken by mouth is destroyed by gastric juices in the stomach. 4 Oral hypoglycemics work the same way as insulin to treat mild diabetes.
3 To be effective, insulin must be administered subcutaneously, where it can be absorbed; gastric juices destroy insulin taken by mouth. The other person probably has type 2 diabetes, which may be controlled with oral hypoglycemics, as well as by diet and exercise. Oral hypoglycemics are not related to lipodystrophy; repeated injections of insulin may cause lipodystrophy. Oral hypoglycemics are not insulin; they either increase insulin secretion from the islet cells of the pancreas or increase the insulin sensitivity of extrapancreatic tissues in clients with type 2 diabetes.
A client is admitted to the hospital for a subtotal thyroidectomy. When discussing postoperative drug therapy with the client, the nurse should teach the client to: 1 Take the iodine daily to increase the formation of thyroid hormone 2 Understand that medication will be temporary until the body adjusts to postsurgical activities 3 Take the propylthiouracil that is prescribed to stimulate the secretion of thyroid-stimulating hormone 4 Report palpitations, nervousness, tremors, or loss of weight that may indicate an overdose of thyroid hormone
4 Excessive thyroid hormone replacement may lead to signs and symptoms of hyperthyroidism. Iodine may be administered before, not after, surgery. Thyroid hormone replacement is required for life. Propylthiouracil blocks thyroid hormone synthesis; this often is administered before, not after, surgery.
A client is diagnosed as having type 2 diabetes. A priority teaching goal is, "The client will be able to: 1 Perform foot care daily." 2 Administer insulin as prescribed." 3 Test urine for both sugar and acetone." 4 Identify pending hypoglycemia or hyperglycemia.
4 Knowledge of the signs and treatment for hypoglycemia or hyperglycemia is critical to client health and well-being and essential for survival. Although performing foot care daily is important, it is not the priority. The client has type 2 diabetes, which usually is controlled by oral hypoglycemics. Self-serum glucose monitoring is more accurate than sugar and acetone (S&A) urine measurements to identify serum glucose levels.
A client is admitted with a diagnosis of chronic adrenal insufficiency. When assigning a room, which roommate should be avoided because of the newly admitted client's condition? 1 Young adult client with pneumonia 2 Adolescent client with a fractured leg 3 Older adult client who had a brain attack 4 Middle-aged client who has cholecystitis
1 Circulatory collapse can be caused by exposure to an infection or a cold or by overexertion of a client with chronic adrenocortical insufficiency (Addison disease). Roommates with a fractured leg, a brain attack, or cholecystitis are appropriate room assignments because they are not communicable infections.
A client with diabetes asks how exercise will affect insulin and dietary needs. The nurse should respond, "Exercise: 1 Increases the need for carbohydrates and decreases the need for insulin." 2 Increases the need for insulin and increases the need for carbohydrates." 3 Decreases the need for insulin and decreases the need for carbohydrates." 4 Decreases the need for carbohydrates but does not affect the need for insulin."
1 Exercise increases the uptake of glucose by active muscle cells without the need for insulin; carbohydrates are needed to supply energy for the increased metabolic rate associated with exercise. The need for insulin is decreased. The need for insulin is decreased, and the need for carbohydrates is increased. The need for insulin is decreased, and the need for carbohydrates is increased.
A client newly diagnosed with type 2 diabetes is receiving glyburide (Micronase) and asks the nurse how this drug works. The nurse explains that glyburide: 1 Stimulates the pancreas to produce insulin 2 Accelerates the liver's release of stored glycogen 3 Increases glucose transport across the cell membrane 4 Lowers blood glucose in the absence of pancreatic function
1 Glyburide, an antidiabetic sulfonylurea, stimulates insulin production by the beta cells of the pancreas. Accelerating the liver's release of stored glycogen occurs when serum glucose drops below normal levels. Increasing glucose transport across the cell membrane occurs in the presence of insulin and potassium. Antidiabetic medications of the chemical class of biguanide improve sensitivity of peripheral tissue to insulin, which ultimately increases glucose transport into cells. Beta cells must have some function to enable this drug to be effective.
An obese client with type 2 diabetes asks about the intake of alcohol or special "dietetic" food in the diet. The nurse teaches the client that: 1 Alcohol can be consumed, with its calories counted in the diet 2 Unlimited amounts of sugar substitutes can be used as desired 3 Alcohol should not be used in cooking because it adds too many calories 4 Special "dietetic" foods are needed because many regular foods cannot be used
1 In the overweight individual with type 2 diabetes, occasional alcohol can be ingested with caloric substitution for equivalent fat exchanges in the diet because it is metabolized like fat. Moderation is vital; sugar substitutes may not be used in unlimited quantities and they must be accounted for in the dietary calculations. Alcohol can be used as long as it is accounted for in the diet. The statement that special "dietetic" foods are needed because many regular foods cannot be used is untrue; regular foods can be used in the diet of individuals with diabetes.
While the nurse is at the bedside of a client in acute renal failure, the client states, "My health care provider said that I will be getting some insulin. Do I also have diabetes?" What is the best nursing response? 1 "No, the insulin will help your body handle the increased potassium level." 2 "I suggest that you ask your health care provider that question." 3 "You probably had an elevated blood glucose level, so your health care provider is being cautious." 4 "No, but insulin will reduce the toxins in your blood by lowering your metabolic rate."
1 Insulin promotes the transfer of potassium into cells, which reduces the circulating blood level of potassium. The response "I suggest that you ask..." halts communication and is not supportive. Blood glucose levels usually are not elevated in acute renal failure. Insulin will not lower the metabolic rate.
A client has a thyroidectomy for cancer of the thyroid. To evaluate for nerve injury that may be the result of surgery-related trauma, the nurse assesses the client's ability to: 1 Speak 2 Swallow 3 Purse the lips 4 Turn the head
1 The laryngeal nerve is close to the operative site and can be damaged inadvertently. Loss of the gag reflex occurs with general anesthesia; the ability to swallow signifies its return. The ability to purse the lips tests the seventh cranial (facial) nerve, which is not affected in thyroid surgery. The nerves involved in turning the head are not near the thyroid gland.
A nurse is assessing a client with a diagnosis of hypothyroidism. Which clinical manifestations should the nurse expect when assessing this client? Select all that apply. 1 Dry skin 2 Brittle hair 3 Weight loss 4 Resting tremors 5 Heat intolerance
1,2 Dry skin results from a decrease in the metabolic rate, which is associated with hypothyroidism. Dry, brittle hair results from a decrease in the metabolic rate, which is associated with hypothyroidism. Weight loss is associated with hyperthyroidism because of an increase in body metabolism. Resting tremors are not associated with hypothyroidism; they are associated with Parkinson disease. Heat intolerance is associated with hyperthyroidism, not hypothyroidism, because of the increase in body metabolism.
The nurse is planning discharge instructions for a client who had a thyroidectomy. For which signs of surgically induced hypothyroidism should the nurse alert the client? Select all that apply. 1 Fatigue 2 Dry skin 3 Insomnia 4 Excitability 5 Weight loss 6 Intolerance to heat
1,2, Fatigue results from the decreased metabolic rate associated with hypothyroidism. Dry skin is caused by decreased glandular function. Insomnia is associated with hyperthyroidism because of the increased metabolic rate. Lethargy, not excitability, is associated with hypothyroidism because of the decreased metabolic rate. Weight gain, not loss, is associated with hypothyroidism because of the decreased metabolic rate. Intolerance to heat is associated with hyperthyroidism.
The nurse is providing instructions about foot care for a client with diabetes mellitus. What should the nurse include in the instructions? Select all that apply. 1 Wear shoes when out of bed. 2 Soak the feet in warm water daily. 3 Dry between the toes after bathing. 4 Remove corns as soon as they appear. 5 Use a heating pad when the feet feel cold
1,3 Wearing shoes protects the feet from trauma; they should fit well and should be worn over clean socks. Drying between the toes after bathing prevents maceration and skin breakdown, thus maintaining skin integrity. Soaking the feet is contraindicated because it can cause macerations and skin breakdown, which allow a portal of entry for pathogenic organisms. Clients should not self-treat corns, calluses, warts, or ingrown toenails because of the potential for trauma and skin breakdown; these conditions should be treated by a podiatrist. Use of a heating pad, hot water bottle, or hot water is contraindicated because of the potential for burns; diabetic neuropathy, if present, does not allow the client to accurately evaluate the extremes of temperature.
While hospitalized, a client with diabetes is observed picking at calluses on the feet. The nurse should immediately: 1 Warn the client of the danger of infection 2 Suggest that the client wear white cotton socks 3 Teach the client the importance of effective foot care 4 Check the client's shoes for their fit in the area of the calluses
3 Inadequate foot care can lead to skin breakdown, poor healing, and subsequent infection. Warning the client of the danger of infection can increase anxiety and reduce the client's ability to learn. Suggesting that the client wear white cotton socks is only one aspect of effective foot care; synthetic fibers that wick moisture are preferred. Although important, checking the client's shoes for their fit in the area of the calluses is not comprehensive foot care.
On the first postoperative day following a thyroidectomy, a client tolerates a full-fluid diet. This is changed to a soft diet on the second postoperative day. The client reports having a sore throat when swallowing. What should the nurse do first? 1 Reorder the full-fluid diet. 2 Notify the health care provider. 3 Administer analgesics as prescribed before meals. 4 Provide saline gargles to moisten the mucous membranes.
3 Soreness is to be expected. A progression to a soft diet will provide nutrients needed for healing and energy and will stimulate the return of bowel activity. Analgesics as prescribed will reduce soreness during meals. Reordering the full-fluid diet is not within the legal role of the nurse. Soreness is to be expected; this is not an emergency necessitating medical action. The soreness is not because of drying; when the client is at home, humidified air might help reduce the soreness, but it will not help the client eat the soft diet. Gargling involves hyperextension of the neck which may put tension on the suture line.
A client with diabetes is given instructions about foot care. The nurse determines that the instructions are understood when the client states, "I will: 1 Cut my toenails before bathing." 2 Soak my feet daily for one hour." 3 Examine my feet using a mirror at least once a week." 4 Break in my new shoes over the course of several weeks."
4 A slower, longer period of time to break in new, stiff shoes will help prevent blisters and skin breakdown. The toenails should be cut by a podiatrist; they usually are cut after a foot bath when the nails are softer. Soaking the feet daily for one hour will cause maceration of the skin and should be avoided. Examining the feet using a mirror at least once a week is too long a period of time; the client should examine the feet daily for signs of trauma.
A client with hyperthyroidism is to receive potassium iodide solution before a subtotal thyroidectomy is performed. The nurse concludes that this medication is given to: 1 Decrease the total basal metabolic rate 2 Maintain the function of the parathyroids 3 Block the formation of thyroxine by the thyroid gland 4 Decrease the size and vascularity of the thyroid gland
4 Potassium iodide aids in decreasing the vascularity of the thyroid gland, which limits the risk of hemorrhage when surgery is performed; it should be given no longer than 10 to 14 days before surgery because its effect is temporary. Thyroid hormone substitutes regulate the body's metabolism. Maintaining the function of the parathyroids is not the therapeutic action of potassium iodine. The parathyroid glands help regulate adequate levels of calcium in the blood. When hypocalcemia occurs, the parathyroid glands increase the absorption of calcium from urine and the intestine and stimulate the breakdown of bone matrix, increasing the release of calcium from bone. Antithyroid drugs, not iodine, prevent the formation of thyroxine.
A client had a thyroidectomy. The nurse monitors for thyrotoxic crisis, which is evidenced by: 1 An increased pulse deficit 2 A decreased blood pressure 3 A decreased heart rate and respirations 4 An increased temperature and pulse rate
4 These symptoms may indicate impending hypocalcemic tetany, a complication after removal of parathyroid tissue during a thyroidectomy. Physical assessment and notification of the health care provider are the priorities. These symptoms may be related to postoperative anxiety, but the priority is to assess for impending tetany. Taking the vital signs and placing the client in a high-Fowler position is not helpful for the complaint made by the client; further assessment for tetany is indicated.
A nurse is providing postoperative care for a client who just had a thyroidectomy. For what response should the nurse assess the client when concerned about the potential risk of thyrotoxic crisis? 1 Elevated serum calcium 2 Sudden drop in pulse rate 3 Hypothermia and dry skin 4 Rapid heartbeat and tremors
4 Thyrotoxic crisis (thyroid storm) refers to a sudden and excessive release of thyroid hormones, which causes pyrexia, tachycardia, and exaggerated symptoms of thyrotoxicosis; surgery, infection, and ablation therapy can precipitate this life-threatening condition. Hypercalcemia is not related to thyrotoxic crisis; hypocalcemia results from accidental removal of the parathyroid glands. Tachycardia is an increased, not decreased, heart rate, which occurs with thyrotoxic crisis because of the sudden release of thyroid hormones; thyroid hormones increase the basal metabolic rate. Fever, not hypothermia, and diaphoresis, not dry skin, occur with thyrotoxic crisis because of the sudden release of thyroid hormones, which increase the basal metabolic rate.
