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Review Questions - NCLEX® Examination - Chapter 37 Question 15 of 26 The client in shock has the following vital signs: T 99.8° F, P 132 beats/min, R 32 breaths/min, and BP 80/58 mm Hg. Calculate the pulse pressure.

22 mm Hg Pulse pressure is the difference between the systolic and diastolic pressures: 80 (systolic) - 58 (diastolic) = 22 (pulse pressure)

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

Hepatitis B can be spread through sexual contact, needle sharing, needle sticks, blood transfusions, hemodialysis, acupuncture, and the maternal-fetal route. A person with multiple sexual partners has more opportunities to contract the infection. Hepatitis B is not transmitted through medications, casual contact with other travelers, or raw shellfish. Although an overdose of acetaminophen can cause liver cirrhosis, this is not associated with hepatitis B. Hepatitis E is found most frequently in international travelers. Hepatitis A is spread through ingestion of contaminated shellfish.

26. Which class of antidiabetic medication should be taken with the first bite of a meal to be fully effective? a. Alpha-glucosidase inhibitors, which include miglitol (Glyset) b. Biguanides, which include metformin (Glucophage) c. Meglitinides, which include nateglinide (Starlix) d. Second-generation sulfonylureas, which include glipizide (Glucotrol)

27. The nurse is caring for a patient with DI. What is the priority goal of collaborative care? a. Correct the water metabolism problem. b. Control blood sugar and blood pH. c. Measure urine output, specific gravity, and osmolality hourly. d. Monitor closely for respiration distress.

28. Which medication is used to treat DI? a. Desmopressin acetate (DDAVP) b. Lithium (Eskalith) c. Vasopressin (Pitressin) d. Demeclocycline (Declomycin)

37. A patient will be using an external insulin pump. What does the nurse tell the patient about the pump? a. SMBG levels should be done three or more times a day.. b. The insulin supply must be replaced every 2 to 4 weeks. c. The pump's battery should be checked on a regular weekly schedule. d. The needle site must be changed every day.

37. The nurse is caring for a patient with sepsis. What is a late clinical manifestation of shock? a. Drop in blood pressure b. MAP is decreased by less than 10 mm Hg c. Tachycardia with a bounding pulse d. Increased urine output

40. A patient with diabetic ketoacidosis is on an insulin drip of 50 units of regular insulin in 250 mL of normal saline The current blood glucose level is 549 mg/dL. According to insulin protocol, the insulin drip needs to be changed to 8 units per hour. At what rate does the nurse set the pump? a. 40 mL/hr b. 50 mL/hr c. 60 mL/hr d. 75 mL/hr

46. The nurse is caring for a patient in septic shock. The nurse notes that the rate and depth of respirations is markedly increased. The nurse interprets this as a possible manifestation of the respiratory system compensating for which condition? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis

46. The patient's urinalysis shows proteinuria. Which pathophysiology does the nurse suspect? a. Nephropathy b. Neuropathy c. Retinopathy d. Gastroparesis

48. The nurse determines a priority patient problem of altered self-concept in a female patient with Cushing's syndrome who expresses concern about the changes in her general appearance. What is the expected outcome for this patient? a. To verbalize an understanding that treatment will reverse many of the problems b. To ventilate about the frustration of these lifelong physical changes c. To verbalize ways to cope with the changes such as joining a support group or changing style of dress d. To achieve a personal desired level of sexual functioning

49. Which drug is an adrenal cytotoxic agent used for inoperable adrenal tumors? a. Mitotane (Lysodren) b. Aminoglutethimide (Cytadren) c. Cyprohepatadine (Periactin) d. Fludrocortisone (Florinef)

54. Which patient is at risk for developing secondary adrenal insufficiency? a. Patient who suddenly stops taking high-dose steroid therapy b. Patient who tapers the dosages of steroid therapy c. Patient deficient in ADH d. Patient with an adrenal tumor causing excessive secretion of ACTH

Question 19 of 26 A client with terminal lung cancer is receiving hospice care at home. Which nursing action does the RN manager ask the LPN/LVN to do? a. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. b. Clarify family members' feelings about the meaning of client behaviors and symptoms. c. Develop a plan for care after assessing the needs and feelings of both the client and the family. d. Teach the family to recognize signs of client discomfort such as restlessness or grimacing.

a Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client is appropriate to delegate to the LPN/LVN. Clarifying family members' feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level.

Question 16 of 26 A dying client exhibits signs of agitation. The Foley catheter has drained 100 mL in the last 3 hours, and the client's last bowel movement was yesterday evening. What does the nurse do first? a. Administers an analgesic b. Arranges for a consultation with a bereavement counselor c. Assesses the client for impaction d. Changes the Foley catheter to ensure adequate drainage

a Administers an analgesic Agitation may be indicative of pain, which must be addressed in the dying client. Arranging for a consultation with a counselor is not the priority in this situation. The dying client's metabolism has slowed, so assessing for impaction may not be necessary. The Foley catheter should not be changed, but the tubing should be assessed to ensure that there are no kinks.

23. What is the disorder that results from a deficiency of vasopressin (ADH) from the posterior pituitary gland called? a. SIADH b. DI c. Cushing's syndrome d. Addison's disease

28. The nurse is caring for a postoperative patient who had major abdominal surgery. Which assessment finding is consistent with hypovolemic shock? a. Pulse pressure of 40 mm Hg b. A rapid, weak, thready pulse c. Warm, flushed skin d. Increased urinary output

60. The UAP working under supervision of an RN is checking vital signs on the patient at risk for hypovolemic shock. Which instruction must the nurse give the UAP? a. Report any increase in heart rate because it is an early sign of shock. b. Report any increased systolic pressure, which is an early sign of shock. c. Report any changes in body temperature, which may indicate sepsis. d. Report any increase in respiratory rate because of acid-base changes.

Iggy Study Guide Ch.59 1. A patient is admitted to the patient care unit with obstructive jaundice. which sign/symptom does the nurse expect to find upon assessment of the patient? a. Pruritus b. Pale urine in increased amounts c. Pink discoloration of sclera d. Dark, tarry stools

45. When administering norepinephrine (Levophed), what does the nurse monitor for in the patient? (Select all that apply.) a. Extravasation b. Headache c. High-output renal failure d. Chest pain e. Hypertension

a, b, d, e

3. A malfunctioning anterior pituitary gland can result in which disorder? (Select all that apply.) a. Pituitary hypofunction b. Pituitary hyperfunction c. DI d. Hypothyroidism e. Osteoporosis

a, b, d, e Pituitary hypofunction Pituitary hyperfunction Hypothyroidism Osteoporosis

20. While caring for a postoperative patient following a transsphenoidal hypophysectomy, the nurse observes nasal drainage that is clear with yellow color at the edge. This "halo sign" is indicative of which condition? a. Worsening neurologic status of the patient b. Drainage of CSF from the patient's nose c. Onset of postoperative infection d. An expected finding following this surgery

21. A young trauma patient is at risk for hypovolemic shock related to occult hemorrhage. what baseline indicator allows the nurse to recognize the early signs of shock? a. Urine output b. Pulse rate c. Fluid intake d. Skin color

26. A patient is showing early clinical manifestations of hypovolemic shock. The provider orders an arterial blood gas (ABG). Which ABG values does the nurse expect to see in hypovolemic shock? a. Increased pH with decreased PaO2 and increased PaCO2 b. Decreased pH with decreased PaO2 and increased PaCO2 c. Normal pH with decreased PaO2 and normal PaCO2 d. NOrmal pH with decreased PaO2 and decreased PaCO2

76. From which injection site is insulin absorbed most rapidly? a. Buttocks b. Abdomen c. Deltoid d. Thigh

81. The critical care nurse is caring for an older patient admitted with HHS. What is the first priority in caring for this patient? a. Slowly decreasing blood glucose b. Fluid replacement to increase blood volume c. Potassium replacement to prevent hypokalemia d. Diuretic therapy to maintain kidney function

6. Which individual is at greatest risk for developing type 2 DM? a. 25-year-old American woman b. 36-year-old African man c. 56-year-old Hispanic Woman d. 40-year-old Hispanic man

60. Which statement about sexual intercourse for patients with diabetes is true? a. The incidence of sexual dysfunction is lower in men than women. b. Retrograde ejaculation does not interfere with male fertility. c. Impotence is associated with DM in male patients. d. Sexual dysfunction in female patients includes inability to achieve pregnancy

62. Which statement by a patient with DM indicates an understanding of the principles of self-care? a. "I don't like the idea of sticking myself so often to measure my sugar." b. "I plan to measure the sugar in my urine at least four times a day." c. "I plan to get my spouse to exercise with me to keep me company." d. "If I get a cold, I can take my regular cough medication until I feel better."

63. After a 2-hour glucose challenge, which result demonstrates impaired glucose tolerance? a. Less than 100 mg/dL b. Less than 140 mg/dL c. Greater than 140 mg/dL d. Greater than 250 mg/dL

9. In a patient with hyperglycemia, the respiratory center is triggered in an attempt to excrete more carbon dioxide and acid, thus causing a rapid and deep respiratory pattern. What is the term for this respiratory pattern? a. Tachypnea b. Cheyne-Stokes respiration c. Kussmaul respiration d. Biot respiration

9. Which symptom is most distressing and feared by terminally ill patients? a. Difficulty breathing b. Confusion c. Pain d. Loss of consciousness

Iggy Study Guide Ch.59 15. The female patient is to have her gallbladder removed by natural orifice transluminal endoscopic surgery. What does the nurse teach about this surgery? a. The surgeon will use powerful shock waves to break up the gallstones. b. The surgeon will insert a transhepatic billiary catheter to open blocked bile ducts. c. The surgeon will use a vaginal approach to remove your gallbladder. d. The surgeon will inject ursodeoxycholic acid to dissolve any remaining gallstone fragments.

Iggy Study Guide Ch.59 2. The daughter of a patient with cholelithiasis has heard that there is a genetic disposition for cholelithiasis. The daughter asks the nurse about the risk factors. How does the nurse respond? a. "There is no evidence that first-degree relatives have an increased risk for this disease." b. "Cholecystitis is seen more frequently in patients who are underweight." c. "Hormone replacement therapy has been associated with increased risk for cholecystitis." d. "Patients with diabetes mellitus are at increased risk for cholecystitis."

Question 7 of 26 A nurse who is skilled in complementary and alternative medicine (CAM) therapies works on a cancer unit with clients who are terminally ill. For which client symptom does the nurse use these therapies? a. Constipation b. Cool extremities c. Increased pain d. Memory loss

c Increased pain CAM can help relieve pain and agitation, minimizing the need for increased opioids. CAM is not typically used for constipation or to deal with cool extremities. Memory loss is not a symptom that should receive priority in the dying client.

Iggy Study Guide Ch.59 14. Which statement about the care of a patient with a Jackson-Pratt (JP) drain after a traditional cholecystectomy is true? a. The patient is maintained in the prone position. b. When the patient is allowed to eat, the JP drain is clamped continuosuly. c. The JP drain is irrigated every hour for the first 24 hours. d. Serosanguineous drainage stained with bile is expected for 24 hours.

Iggy Study Guide Ch.59 16. After removal of the gallbladder, a patient experiences abdominal pain with vomiting for several weeks. What does the nurse recognize? a. Chronic cholecystitis b. Recurrence of acute cholecystitis c. Unremoved gallstones d. Postcholecystectomy syndrome

9. Which type of psychoactive drug requires the most careful monitoring by the nurse because of the drug's potential for causing confusion and incontinence? a. Tricyclic antidepressants b. Antipsychotics c. Antianxiety agents d. Sedative-hypnotics

10. A patient with a head injury was treated for a cerebral hematoma. After surgery, this patient is at risk for what type of shock? a. Obstructive b. Cardiogenic c. Chemical-induced distributive d. Neural-induced distributive

11. The nurse is performing a morning shift assessment on several patients. For which patient is the nurse immediately concerned about decreased tissue perfusion if the capillary refill time was delayed? a. Patient with diabetes mellitus b. Anemic patient c. Patient with peripheral vascular disease d. Asthmatic patient

12. Which intervention should be done when performing postmortem care? a. Place the head of the bed at 30 degrees. b. Remove pillows from under the head. c. Leave a Foley (indwelling) catheter in place in the bladder. d. Place pads under the hips and around the perineum.

14. A female patient has been prescribed hormone replacement therapy. What does the nurse instruct the patient to do regarding this therapy? a. Report any recurrence of symptoms, such as decreased libido, between injections. b. Monitor blood pressure at least weekly for potential hypotension. c. Treat leg pain, especially in the calves, with gentle muscle stretching. d. Take measures to reduce risk for hypertension and thrombosis.

16. Early treatment of DKA and HHNS includes IV administration of which fluid? a. Glucagon b. Potassium c. Bicarbonate d. Normal saline

20. Which action is an example of active euthanasia for a dying patient? a. Removal of a patient from a mechanical ventilator b. Discontinuing intravenous fluids c. Withdrawal of telemetry heart monitoring d. Administering a large dose of intravenous morphine

28. Which class of antidiabetic medication is most likely to cause a hypoglycemic episode because of the long duration of action? a. Alpha-glucosidase inhibitors, which include miglitol (Glyset) b. Biguanides, which include metformin (Glucophage) c. Meglitinides, which include nateglinide (Starlix) d. Second-generation sulfonylureas, which include glipizide (Glucotrol)

29. Which IV therapy results in the greatest increase in oxygen-carrying capacity for a patient with hypovolemic shock? a. Lactated Ringer's solution b. Hetastarch c. Fresh frozen plasma (FFP) d. Packed red cells

3. Which statement regarding the approach to hospice/end-of-life care is correct? a. Hospice programs only include provision of care in the home. b. Admission to hospice is involuntary and directed by a health care provider's order. c. The focus is on facilitating quality of life just for the dying patient. d. An interdisciplinary team approach is used for the care of the patient and family.

14. A hospice patient is deteriorating and the family is concerned about his restlessness and agitation. Which intervention is the nurse prepared to perform? a. Notify the primary health care provider and request orders for transfer to the hospital. b. Determine if the patient is in pain, provide analgesics, and make the patient as comfortable as possible. c. Initiate IV hydration to provide the patient with necessary fluids. d. Encourage the family to assist the patient to eat in order to gain energy.

16. On assessment of a newly admitted older patient, the nurse notes cigarette burns on the lower abdomen. Which term best describes this finding? a. Neglect b. Physical abuse c. Elder abuse d. Mistreatment

19. Preoperative care for a patient who has had a transphenoidal hypophysectomy includes which intervention? a. Encouraging coughing and deep-breathing to decrease pulmonary complications b. Testing nasal drainage for glucose to determine whether it contains CSF c. Keeping the bed flat to decrease central CSF leakage d. Assisting the patient with brushing the teeth to reduce risk of infection

19. When glucagon is administered, what does it do? a. Competes for insulin at the receptor sites b. Frees glucose from hepatic stores of glycogen c. Supplies glycogen directly to the vital tissues d. Provides a glucose substitute for rapid replacement

27. Which class of antidiabetic medication must be held after using contrast media until adequate kidney function is established? a. Alpha-glucosidase inhibitors, which include miglitol (Glyset) b. Biguanides, which include metformin (Glucophage) c. Meglitinides, which include nateglinide (Starlix) d. Second-generation sulfonylureas, which include glipizide (Glucotrol)

3. Why is glucose vital to the body's cells? a. It is used to build cell membranes. b. It is used by cells to produce energy. c. It affects the process of protein metabolism. d. It provides nutrients for genetic material.

30. Which statement about the pathophysiology of SIADH is correct? a. ADH secretion is inhibited in the presence of low plasma osmolality. b. Water retention results in dilutional hyponatremia and expanded extracellular fluid (ECF) volume. c. The glumerulus is unable to increase its filtration rate to reduce the excess plasma volume. d. Renin and aldosterone are released and help decrease the loss of urinary sodium.

32. A patient is in hypovolemic shock related to hemorrhage from a large gunshot wound. Which order must the nurse question? a. Establish a large-bore peripheral IV and give crystalloid bolus. b. Give furosemide (Lasix) 20 mg slow IVP. c. Insert a Foley catheter and monitor intake and output. d. GIve high-flow oxygen via mask at 10 L/min.

33. The nurse is performing a psychosicial assessment on a patient who is at risk for shock. Which statement made by the patient is of greatest concern to the nurse? a. "Do you have any idea when I might to home? No one is feeding my cat." b. "Something feels wrong, but I'm not sure what is causing me to feel this way." c. "I live alone in my house and my family lives in a different state." d. "I would usually go golfing with my friends today. I hope they're not worried about me."

33. Which statement about insulin is true? a. Exogenous insulin is necessary for management of all cases of type 2 DM. b. Insulin's effectiveness depends on the individual patient's absorption of the drug. c. Insulin doses should be regulated according to self-monitoring urine glucose levels. d. Insulin administered in multiple doses per day decreases the flexibility of a patient's lifestyle

70. What glucose level range does the American Association of Clinical Endocrinologists recommend for a critically ill patient? a. Between 100 and 130 mg/dL b. Between 140 and 180 mg/dL c. Between 180 and 200 mg/dL d. Between 200 and 240 mg/dL

2. Which hormones are released in response to decreased mean arterial pressure (MAP)? (Select all that apply.) a. Insulin b. Renin c. Antidiuretic hormone (ADH) d. Epinephrine e. Aldosterone f. Serotonin

b, c, d, e

66. A patient has been diagnosed with DM. Which aspects does the nurse consider in formulating the teaching plan for this patient? (Select all that apply.) a. Covering all needed information in one teaching session. b. Assessing visual impairment regarding insulin labels and markings on syringes. c. Assessing manual dexterity to determine if the patient is able to draw insulin into a syringe d. Assessing patient motivation to learn and comprehend instructions e. Assessing the patient's ability to read printed material

b, c, d, e

18. After a hypophysectomy, home care monitoring by the nurse includes assessing which factors? (Select all that apply.) a. Hypoglycemia b. Bowel habits c. Possible leakage of cerebrospinal fluid (CSF) d. 24-hour intake of fluids and urine output e. 24-hour diet recall f. Activity level

b, c, d, e, f

5. Which patients are at risk for shock related to fluid shifts? (Select all that apply.) a. Hypoglycemic patient b. Severely malnourished patient c. Patient with paralytic ileus d. Patient with kidney disease e. Patient with minor burns f. Patient with large wounds

b, c, d, f

58. The nurse determines that the administration of hydrocortisone for the Addisonian crisis is effective when which assessment is made? a. Increased urine output b. No signs of pitting edema c. Weight gain d. Lethargy improving; patient alert and oriented

59. Which nursing intervention is a preventive measure for adrenocortical insufficiency? a. Maintaining diuretic therapy b. Instructing the patient on salt restriction c. Reducing high-dose glucocorticoid therapy quickly d. Reducing high-dose glucocorticoid doses gradually

p. 112, Safe and Effective Care Environment The emergency department nurse is assigned to five clients waiting for orders to be implemented. Which client does the nurse assess first? A. 60-year-old waiting for transport to the operating room for an emergency appendectomy B. 25-year-old with a closed femur fracture who received pain medication 10 minutes ago C. 30-year-old with nausea and vomiting who has IV fluids infusing and is now sleeping D. 28-year-old construction worker with a laceration to the arm that is waiting to be sutured

A Rationale: The 60-year old client is scheduled for an emergent surgery and needs to be assessed to be transported. The other clients are stable at this time or have less life-threatening health problems.

The Patient with Septic Shock A 72-year-old male patient has been living in an assited-living facility. He is generally alert, cheerful, and ambulatory with a walker. He has had frequent bouts of urinary tract infactions secondary to prostate problems and is being treated for high blood pressure. He was discovered today by one of the unlicensed assistive personnel (IAPs) in his room in a lethargic and confused state. He was easily aroused, but irritable and uncooperative with simple commands. He is transported to the emergency department (ED) for an acute change in mental status. On arrival to the ED, vital signs are: blood pressure, 110/70 mm Hg; pulse, 120 beats/min; respirations, 30 breaths/min; and temperature, 101F (38.3C). 4. What is the purpose of the sepsis resuscitation and management bundles? Discuss the care and interventions of the patient using the bundle approach.

A bundle is a group of two or more specific interventions that have been shown to be effective when applied together or in sequence. (Refer to Table 37-5 in the text.)

Iggy ch.59 p. 1218 A client had an open Whipple procedure yesterday for pancreatic cancer. Which nursing interventions are appropriate for this client? Select all that apply. A. Monitor and document the client's nasogastric tube drainage. B. Place the client in a side-lying position to promote wound drainage. C. Assess the abdomen for signs of peritonitis. D. Monitor the client's hemoglobin and hematocrit. E. Check the client's blood glucose frequently.

A, C, D, E Rationale: Immediately after surgery, the client who has had an open Whipple procedure is NPO (nothing by mouth) and usually has a NGT tube to decompress the stomach. Monitor gastrointestinal drainage and tube patency. The client should be placed in the semi-Fowler's position to reduce tension on the suture line and anastomosis site as well as to optimize lung expansion. The client should be monitored for signs of peritonitis. Because the open Whipple procedure is extensive and can take many hours to complete, maintaining fluid and electrolyte balance can be difficult. Patients often have significant intraoperative blood loss and postoperative bleeding, so hemoglobin and hematocrit should be monitored. Immediately after the Whipple procedure, the patient may have hyperglycemia or hypoglycemia as a result of stress and surgical manipulation of the pancreas, so frequent monitoring of glucose is important.

After teaching a client who has a history of cholelithiasis, the nurse assesses the client's understanding. Which menu selection made by the client indicates the client clearly understands the dietary teaching? a. Lasagna, tossed salad with Italian dressing, and low-fat milk b. Grilled cheese sandwich, tomato soup, and coffee with cream c. Cream of potato soup, Caesar salad with chicken, and a diet cola d. Roasted chicken breast, baked potato with chives, and orange juice

ANS: D Clients with cholelithiasis should avoid foods high in fat and cholesterol, such as whole milk, butter, and fried foods. Lasagna, low-fat milk, grilled cheese, cream, and cream of potato soup all have high levels of fat. The meal with the least amount of fat is the chicken breast dinner.

p. 754, Patient-Centered Care; Evidence-Based Practice; Safety The patient is a 70-year-old man undergoing chemotherapy for lymphoma who was brought to the hospital by his wife because he was confused. His vital signs are: T = 95.7° F (35.4° C); P = 112; R = 28; BP = 96/50; SpO2 = 84%. His health history includes type 2 diabetes, a myocardial infarction 10 years ago (he now has an "on-demand" pacemaker), and hypertension. In addition to chemotherapy, his current oral medications include metformin (Glucophage) 850 mg twice daily, losartan (Cozaar) 50 mg daily, and aspirin 81 mg daily. When you ask whether there have been any changes lately, the wife tells you that he had a "touch" of fungal pneumonia 6 weeks ago and still has a cough with sputum. He has been very uncomfortable for the past week with a "boil" near his rectum. When you assess his perianal region, you find a large raised red bump with an open area draining purulent fluid. 1. What risk factors does this man have for sepsis? Explain why each factor increases his risk.

Although he is not older than 80 years, his age coupled with the chemotherapy for lymphoma really suppresses his immune system. Diabetes increases his risk for infection even without the chemotherapy. The perianal abscess is very likely the source of the sepsis. The fungal pneumonia, although less likely to be the source of sepsis than the perianal abscess, takes months to clear and would make any hypoxia worse, thus contributing to problems resulting from sepsis. Aspirin therapy does not lead directly to sepsis but would make the clotting problems of late sepsis worse.

p. 99, Physiological Integrity The nurse is caring for a client who has severe dyspnea because of end-stage chronic obstructive pulmonary disease. Which interventions are the most appropriate to help improve his breathing? Select all that apply. A. Administer morphine sulfate on an around-the-clock schedule. B. Teach the client and family to keep him in a sitting position. C. Use a large electric fan to circulate the air. D. Keep the room temperature warm to prevent respiratory infection. E. Teach the client and family that he should use bronchodilators as prescribed.

Answer: A, B, C, E Rationale: Morphine helps to alleviate the work of breathing and is the first-line treatment for dyspnea near death. Bronchodilators open the airways to help with oxygen flow into and out of the lungs. Sitting the client in an upright position helps increase chest expansion; a fan to circular room air also helps with breathing.

p. 97, Physiological Integrity A client with metastasis to the bone is receiving IV antibiotics for pneumonia but has declined further treatment for his disease. He is experiencing severe back pain rated as a 9 on a 0-to-10 scale. What interventions are the most appropriate for the nurse to implement for this client? Select all that apply. A. Provide both non-opioid and opioid analgesics. B. Offer music therapy to help the client relax and decrease anxiety. C. Obtain an order for physical therapy to encourage ambulation. D. Help the client assume the best position of comfort. E. Offer Reiki therapy, if available.

Answer: A, B, D, E Rationale: The client has a terminal illness that is very painful. Therefore, comfort and relaxation measures only are required at this time. He is likely too weak to walk with severe bone pain.

As soon as the antibiotics are available (after blood cultures are obtained), administer them. Monitor vital signs at least hourly. Check with the health care provider about placing an indwelling catheter to monitor hourly urine output and to obtain a specimen for culture. Performing the urine culture after the rest of the cultures and even after the antibiotics is less critical for a man because the urine is less likely to be the source of infection.

Clinical Judgment Challenges IGGY Ch64 p. 1332, Safety; Quality Improvement; Teamwork and Collaboration The patient is a 60 year-old-woman who is 1 day postoperative after a total knee replacement. She has type 2 diabetes and just recently was switched from oral antidiabetic drugs to an insulin regimen. She let her nurse know that her on-demand lunch has been ordered. The nurse tests her blood and gives her the prescribed short-acting insulin dose. An hour later, the physical therapist finds her pale, confused, and clammy. Her lunch tray is on her table and appears totally untouched. 2. What is your first action? Provide a rationale.

Check her blood glucose level immediately because the methods to increase her blood glucose level are dependent on how low the current level is. a. As an alternative, if there is an easily digestible carbohydrate on her tray and she is able to swallow, you could give that to her immediately and then obtain a blood glucose measurement. However, this is less precise.

Clearly, there was a delay in eating after receiving the insulin. The tray may have been delayed longer than expected from food service, or perhaps she decided she was not hungry when it first arrived. She could have been interrupted (possible phone call or visitor) before she had a chance to eat it. In addition, it is possible because she has only recently been started on insulin that she did not understand the necessity of eating soon after receiving insulin.

p. 747, Patient-Centered Care; Evidence-Based Practice; Safety Your patient is a 40-year-old woman who is returned to your ambulatory care unit after having a cholecystectomy (gall bladder removal) performed as minimally invasive surgery by laparoscopy. After moving her from the stretcher to her bed, you take her vital signs. Her pulse is 118 and thready, blood pressure is 88/72, respiratory rate is 28, and pulse oxymetry is 88%. When you call her name, she opens her eyes but does not answer any questions. 2. What manifestations of shock are present based on the information you currently have?

The major manifestations of shock this patient has are a rapid pulse, narrowed pulse pressure, oxygen saturation below 98% (she is young and, with no other health problems, should have an oxygen saturation of 98% or higher), and she is not responding to questions.

p. 95, Patient-Centered Care A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me." 3. Is the patient a candidate for hospice at this time? Why or why not?

The patient likely has Medicare, which will pay for the hospice benefit if needed. However, the patient must be expected to live less than 6 months for this benefit to apply. Her primary care provider would need to make that determination.

Clinical Judgment Challenge p. 1335, Prioritization, Delegation, and Supervision The patient, a 21-year-old college student, was brought to the emergency department (ED) by his roommate. He reports abdominal pain, polyuria for the past 2 days, vomiting several times prior to arrival, and extreme thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He demonstrates deep rapid respirations; there is a fruit odor to his breath. He has type 1 diabetes and "may have skipped a few doses of insulin because of cramming for final exams." He is alert and talking but is having trouble focusing on your questions. Blood pressure 110/60 Pulse 110/min Respirations 32/min Temperature 100.8F Fingerstick glucose 485 mg/dL Oxygen saturation 99% 5. In caring for this patient, what immediate intervention do you anticipate the ED physician will order to be performed first? Provide a rationale for your choice.

The patient needs IV fluids to correct fluid deficit that places him at risk for hypovolemic shock. Also, he needs carefully regulated insulin therapy at this time, which is best accomplished by the IV route. Subcutaneous insulin does not absorb fast enough and is inappropriate for emergency situations.

The Patient with Hypovolemic Shock A 38-year-old female patient returned to the postanesthesia recovery unit (PACU) 2 hours ago after undergoing a tubal ligation by colposcopy (through the back wall of the vagina behind the cervix). Her last documented vital signs, taken 30 minutes ago, were blood pressure, 102/80 mm Hg, pulse, 88 Beats/min, and respirations, 22 beats/min. The nurse now notes that her face is pale and the skin around her lips has a bluish cast. she reports some back pain. Her vital signs are now blood pressure, 90.76 mm Hg, pulse, 98 beats/min, and respirations, 28 breaths/min. 4. What expected outcomes would be specific to this situation?

The patient should have improved oxygenation as evidenced by pink oral mucous membranes and a peripheral oxygen saturation of 95%. The source of the hemorrhage will be identified. The patient's vital signs will not worsen before the appropriate surgical intervention is initiated.

9. When analyzing laboratory values, the nurse expects to find which value as a direct result of overproduction of GH? a. Hyperglycemia b. Hyperphosphatemia c. Hypocalcemia d. Hypercalcemia

a Hyperglycemia

10. Which electrolyte is most affected by hyperglycemia? a. Sodium b. Chloride c. Potassium d. Magnesium

Review Questions - NCLEX® Examination - Chapter 37 Question 14 of 26 A client with septic shock is to receive dopamine at 18 mcg/kg/min. The client's weight is 154 pounds. How many mcg/min does the nurse administer?

1260 mcg/min First convert pounds to kilograms: 154 lb ÷ 2.2 = 70 kg. Then, 70 kg × 18 mcg/kg/min = 1260 mcg/min.

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

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

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

ANS: A A client recovering from chronic pancreatitis should be limited to one floor until strength and activity increase. The client will need a bathroom on the same floor for frequent defecation. Assessing pulse rate and preparation of meals is not specific to chronic pancreatitis. Although the client should be encouraged to stop drinking alcoholic beverages, asking about alcohol availability is not adequate to assess this client's safety.

A nurse assesses a client who is recovering from a Whipple procedure. Which assessment finding alerts the nurse to urgently contact the health care provider? a. Drainage from a fistula b. Absent bowel sounds c. Pain at the incision site d. Nasogastric (NG) tube drainage

ANS: A Complications of a Whipple procedure include secretions that drain from a fistula and peritonitis. Absent bowel sounds, pain at the incision site, and NG tube drainage are normal postoperative findings.

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

ANS: A Rapid removal of ascetic fluid causes decreased abdominal pressure, which can contribute to hypovolemia. This can be manifested by a decrease in urine output to below 30 mL/hr. A slight increase in systolic blood pressure is insignificant. A decrease in respiratory rate indicates that breathing has been made easier by the procedure. The nurse would expect the client's weight to drop as fluid is removed. Six kilograms is less than 3 pounds and is expected.

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

ANS: A The client is not asking the nurse to actually explain why the cancer has occurred. The client may be expressing his or her feelings of confusion, frustration, distress, and grief related to this diagnosis. Reminding the client to keep a positive attitude for his or her family does not address the client's emotions or current concerns. The nurse should validate that there is no easy or straightforward answer as to why the client has cancer. Telling a client that cancer is a trial is untrue and may diminish the client-nurse relationship.

A nurse cares for a client who is recovering from laparoscopic cholecystectomy surgery. The client reports pain in the shoulder blades. How should the nurse respond? a. "Ambulating in the hallway twice a day will help." b. "I will apply a cold compress to the painful area on your back." c. "Drinking a warm beverage can relieve this referred pain." d. "You should cough and deep breathe every hour."

ANS: A The client who has undergone a laparoscopic cholecystectomy may report free air pain due to retention of carbon dioxide in the abdomen. The nurse assists the client with early ambulation to promote absorption of the carbon dioxide. Cold compresses and drinking a warm beverage would not be helpful. Coughing and deep breathing are important postoperative activities, but they are not related to discomfort from carbon dioxide.

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

ANS: A The client with hepatopulmonary syndrome is often dyspneic. Because the oxygen saturation is not significantly low, the nurse should first allow the client to sit upright to see if that helps. If the client remains dyspneic, or if the oxygen saturation drops further, the nurse should investigate adding humidity to the oxygen and seeing whether the client will tolerate that. The other two options may be beneficial, but they are not the best choices. If the client is comfortable, his or her agitation will decrease; this will improve respiratory status.

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

ANS: A The purpose of administering lactulose to this client is to help ammonia leave the circulatory system through the colon. Lactulose draws water into the bowel with its high osmotic gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the bowel. The client must understand that this is an expected and therapeutic effect for him or her to remain compliant. The nurse should not suggest administering anything that would decrease the excretion of ammonia or holding the medication. There is no need to send a stool specimen to the laboratory because diarrhea is the therapeutic response to this medication.

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

ANS: A Treatment of hepatitis C with ribavirin takes up to 48 weeks, making compliance a serious issue. The nurse should work with the client on a strategy to remain compliant for this length of time. Muscle aching is not a common side effect. The client will be on this medication for many weeks and does not need a blood toxicity examination. There is no need for the client to assess his or her radial pulse prior to taking the medication.

A nurse assesses a client who is recovering from an open Whipple procedure. Which action should the nurse perform first? a. Assess the client's endotracheal tube with 40% FiO2. b. Insert an indwelling Foley catheter to gravity drainage. c. Place the client's nasogastric tube to low intermittent suction. d. Start lactated Ringer's solution through an intravenous catheter.

ANS: A Using the ABCs, airway and oxygenation status should always be assessed first, so checking the endotracheal tube is the first action. Next, the nurse should start the IV line (circulation). After that, the Foley catheter can be inserted and the nasogastric tube can be set.

A nurse cares for a client who presents with tachycardia and prostration related to biliary colic. Which actions should the nurse take? (Select all that apply.) a. Contact the provider immediately. b. Lower the head of the bed. c. Decrease intravenous fluids. d. Ask the client to bear down. e. Administer prescribed opioids.

ANS: A, B Clients who are experiencing biliary colic may present with tachycardia, pallor, diaphoresis, prostration, or other signs of shock. The nurse should stay with the client, lower the client's head, and contact the provider or Rapid Response Team for immediate assistance. Treatment for shock usually includes intravenous fluids; therefore, decreasing fluids would be an incorrect intervention. The client's tachycardia is a result of shock, not pain. Performing the vagal maneuver or administering opioids could knock out the client's compensation mechanism.

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

ANS: A, B, E When assessing a client with suspected cirrhosis, the nurse should ask about alcohol consumption, including amount and frequency; sexual history and orientation (specifically men having sex with men); illicit drug use; history of tattoos; and history of military service, incarceration, or work as a firefighter, police officer, or health care provider. A family history of cancer and work as a plumber do not put the client at risk for cirrhosis.

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Oxygen therapy b. Prone position c. Feet elevated on pillows d. Daily weights e. Physical therapy

ANS: A, C, D Care for a client who has hepatopulmonary syndrome should include oxygen therapy, the head of bed elevated at least 30 degrees or as high as the client wants to improve breathing, elevated feet to decrease dependent edema, and daily weights. There is no need to place the client in a prone position, on the client's stomach. Although physical therapy may be helpful to a client who has been hospitalized for several days, physical therapy is not an intervention specifically for hepatopulmonary syndrome.

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

ANS: A, C, D Clients with advanced cirrhosis often have pruritus. Lotion will help decrease itchiness from dry skin. A soft toothbrush should be used to prevent gum bleeding, and the client's nails should be trimmed short to prevent the client from scratching himself or herself. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap.

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

ANS: A, C, D, E Nurses should always use Standard Precautions for client care, and policies should reflect this. Needleless systems and reduction of sharps can help prevent hepatitis. Postexposure prophylaxis should be provided immediately. All health care workers should receive the hepatitis vaccinations that are available.

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

ANS: A, C, E Clients who are prescribed NPO while experiencing an acute pancreatitis episode may need enteral or parenteral nutrition. The nurse should collaborate with the registered dietitian, clinical pharmacist, and health care provider to plan and implement the more appropriate nutritional interventions. The nursing assistant and certified herbalist would not assist with this clinical decision.

A nurse assesses a client with cholelithiasis. Which assessment findings should the nurse identify as contributors to this client's condition? (Select all that apply.) a. Body mass index of 46 b. Vegetarian diet c. Drinking 4 ounces of red wine nightly d. Pregnant with twins e. History of metabolic syndrome f. Glycosylated hemoglobin level of 15%

ANS: A, D, F Obesity, pregnancy, and diabetes are all risk factors for the development of cholelithiasis. A diet low in saturated fats and moderate alcohol intake may decrease the risk. Although metabolic syndrome is a precursor to diabetes, it is not a risk factor for cholelithiasis. The client should be informed of the connection.

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

ANS: B The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

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

ANS: B A low-protein diet is ordered when serum ammonia levels increase and/or the client shows signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has no impact on restoring liver function. Increasing the client's dietary protein will cause complications of liver failure and should not be suggested. Increased intravascular protein will help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary protein.

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

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

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

ANS: B Acetaminophen (Tylenol) can cause liver damage if taken in large amounts. Clients should be taught not to exceed 4000 mg/day of acetaminophen. The nurse should teach the client about this limitation and should explore other drug options with the client to manage his or her arthritis pain. Two glasses of wine each week, a cousin with liver cancer, and the hepatitis vaccine do not place the client at risk for a liver disorder, and therefore do not require any health teaching.

After teaching a client who is recovering from laparoscopic cholecystectomy surgery, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? a. "Drinking at least 2 liters of water each day is suggested." b. "I will decrease the amount of fatty foods in my diet." c. "Drinking fluids with my meals will increase bloating." d. "I will avoid concentrated sweets and simple carbohydrates."

ANS: B After cholecystectomy, clients need a nutritious diet without a lot of excess fat; otherwise a special diet is not recommended for most clients. Good fluid intake is healthy for all people but is not related to the surgery. Drinking fluids between meals helps with dumping syndrome, which is not seen with this procedure. Restriction of sweets is not required.

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

ANS: B Although family members may be afraid that they will contract hepatitis C, the nurse should educate the client's family about how the virus is spread. Viral hepatitis, or hepatitis C, is spread via blood-to-blood transmission and is associated with illicit IV drug needle sharing, blood and organ transplantation, accidental needle sticks, unsanitary tattoo equipment, and sharing of intranasal cocaine paraphernalia. Wearing a gown and gloves will not decrease the transmission of this virus. Hepatitis C is not spread through casual contact or a fecal specimen. The nurse would be violating privacy laws by sharing the client's status with the brother.

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

ANS: B Fever, right quadrant or flank pain, and jaundice are signs of liver transplant rejection; the client should be admitted to the hospital as soon as possible for intervention. Anti-rejection drugs do make a client more susceptible to infection, but this client has signs of rejection, not infection. The nurse should not advise the client to take an additional dose of cyclosporine or acetaminophen as these medications will not treat the acute rejection.

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

ANS: B For safety, the client should void just before a paracentesis. The nurse or the provider should have the client sign the consent form. The proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side of the bed and leaning over the bedside table. The client will be on bedrest after the procedure.

An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a "steering wheel mark" across the client's chest. Which action should the nurse take? a. Ask the client where in the car he or she was sitting during the crash. b. Assess the client by gently palpating the abdomen for tenderness. c. Notify the laboratory to draw blood for blood type and crossmatch. d. Place the client on the stretcher in reverse Trendelenburg position.

ANS: B The liver is often injured by a steering wheel in a motor vehicle crash. Because the client's chest was marked by the steering wheel, the nurse should perform an abdominal assessment. Assessing the client's position in the crash is not needed because of the steering wheel imprint. The client may or may not need a blood transfusion. The client does not need to be in reverse Trendelenburg position.

A nurse cares for a client who is prescribed patient-controlled analgesia (PCA) after a cholecystectomy. The client states, "When I wake up I am in pain." Which action should the nurse take? a. Administer intravenous morphine while the client sleeps. b. Encourage the client to use the PCA pump upon awakening. c. Contact the provider and request a different analgesic. d. Ask a family member to initiate the PCA pump for the client

ANS: B The nurse should encourage the client to use the PCA pump prior to napping and upon awakening. Administering additional intravenous morphine while the client sleeps places the client at risk for respiratory depression. The nurse should also evaluate dosages received compared with dosages requested and contact the provider if the dose or frequency is not adequate. Only the client should push the pain button on a PCA pump.

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

ANS: B The route of acquisition of hepatitis A infection is through close personal contact or ingestion of contaminated water or shellfish. Hepatitis A is not transmitted through medications, blood transfusions, or Epstein-Barr virus. Toxic and drug-induced hepatitis is caused from exposure to hepatotoxins, but this is not a form of hepatitis A. Hepatitis B can be spread through blood transfusions. Epstein-Barr virus causes a secondary infection that is not associated with hepatitis A.

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

ANS: B, C, D During the healing phase of pancreatitis, the client should be provided small, frequent, moderate- to high-carbohydrate, high-protein, low-fat meals. Protein shakes can be provided to supplement the diet. Foods and beverages should not contain caffeine and should be bland.

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

ANS: B, C, D The client should be placed in a private room and dirty linens kept in the client's room until the radiation source is removed. The nurse should wear a lead apron while providing care, ensuring that the apron always faces the client. The nurse should also bundle care to minimize exposure to the client. Transmission-Based Precautions will not protect the nurse from the implanted radioactive iodine seeds.

A nurse assesses a client who is recovering from a Whipple procedure. Which clinical manifestations alert the nurse to a complication from this procedure? (Select all that apply.) a. Clay-colored stools b. Substernal chest pain c. Shortness of breath d. Lack of bowel sounds or flatus e. Urine output of 20 mL/6 hr

ANS: B, C, D, E Myocardial infarction (chest pain), pulmonary embolism (shortness of breath), adynamic ileus (lack of bowel sounds or flatus), and renal failure (urine output of 20 mL/6 hr) are just some of the complications for which the nurse must assess the client after the Whipple procedure. Clay-colored stools are associated with cholecystitis and are not a complication of a Whipple procedure.

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

ANS: B, D Symptoms of hemorrhage and hypovolemic shock include hypotension, tachycardia, tachypnea, pallor, diaphoresis, cool and clammy skin, and confusion

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

ANS: B, D, F The client should be advised to stay sober, and AA is a great resource. The client requires a low-fat diet, and cooking spray is low in fat compared with butter or margarine. If the client smokes, he or she must stop because nicotine can precipitate an exacerbation. A nicotine patch may help the client quit smoking. The client must rest until his or her strength returns. The client requires high carbohydrates and calories for healing; complex carbohydrates are not preferred over simple ones. Dairy products do not cause a problem.

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

ANS: B, E, F Elevated INR and PT are indications of clotting disturbances and alert the nurse to the increased possibility of hemorrhage. Elevated ammonia levels increase the client's confusion. The other values are abnormal and associated with liver disease but do not necessarily place the client at increased risk for complications.

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

ANS: C Paralytic ileus is a common complication of acute pancreatitis. The client should not eat until this has resolved. Bowel sounds and decreased pain are not reliable indicators of peristalsis. Instead, the nurse should assess for passage of flatus or bowel movement.

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

ANS: C The client should be advised to avoid fresh, raw fruits and vegetables because they can be contaminated by tap water. Drinking bottled water, and not sharing plates, glasses, or eating utensils are good ways to prevent illness, as is careful handwashing.

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

ANS: C Before conducting an assessment about the client's feelings, the nurse should determine whether he or she is willing and able to talk about them. If the client is open to the conversation and his or her room is not appropriate, an alternative meeting space may be located. The nurse should be present for the client during this time, and pulling up a chair and sitting with the client indicates that presence. Because the nurse is assessing the client's response to a terminal diagnosis, it is not necessary to have detailed information about the projected prognosis; the nurse knows that the client is facing an end-of-life illness.

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

ANS: C Clients who have chronic cirrhosis may have alienated relatives over the years because of substance abuse. The nurse should assist the client to identify a friend, neighbor, or person in his or her recovery group for support. The nurse should not minimize the client's concerns by brushing off the client's comment. Attending AA may be appropriate, but this response doesn't address the client's concern. Making peace with the client's family may not be possible. This statement is not client-centered.

A nurse assesses a client who has cholecystitis. Which clinical manifestation indicates that the condition is chronic rather than acute? a. Temperature of 100.1° F (37.8° C) b. Positive Murphy's sign c. Light-colored stools d. Upper abdominal pain after eating

ANS: C Jaundice, clay-colored stools, and dark urine are more commonly seen with chronic cholecystitis. The other symptoms are seen equally with both chronic and acute cholecystitis.

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

ANS: C Mutations in both the BRCA2 and p16 genes increase the risk for developing pancreatic cancer in a small number of cases. The other factors do not appear to be linked to increased risk.

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

ANS: C The enzymes should be taken immediately before eating meals or snacks. If the client cannot swallow the capsules whole, they can be opened up and the powder sprinkled on applesauce, mashed fruit, or rice cereal. The client should wipe his or her lips carefully after drinking the enzyme preparation because the liquid could damage the skin. Protein items will be dissolved by the enzymes if they are mixed together.

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

ANS: C The risk of contracting a primary carcinoma of the liver is higher in clients with cirrhosis from any cause. Blunt liver trauma, diabetes mellitus, and chronic malnutrition do not increase a person's risk for developing liver cancer.

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first? a. Sedate the client to prevent tube dislodgement. b. Maintain balloon pressure at 15 and 20 mm Hg. c. Irrigate the gastric lumen with normal saline. d. Assess the client for airway patency.

ANS: D Maintaining airway patency is the primary nursing intervention for this client. The nurse suctions oral secretions to prevent aspiration and occlusion of the airway. The client usually is intubated and mechanically ventilated during this treatment. The client should be sedated, balloon pressure should be maintained between 15 and 20 mm Hg, and the lumen can be irrigated with saline or tap water. However, these are not a higher priority than airway patency.

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

ANS: D Mid-sternal chest pain is indicative of acute angina or myocardial infarction, which can be precipitated by vasopressin. Nausea and vomiting, headache, and vertigo and syncope are not side effects of vasopressin.

A nurse assesses clients on the medical-surgical unit. Which client should the nurse identify as at high risk for pancreatic cancer? a. A 26-year-old with a body mass index of 21 b. A 33-year-old who frequently eats sushi c. A 48-year-old who often drinks wine d. A 66-year-old who smokes cigarettes

ANS: D Risk factors for pancreatic cancer include obesity, older age, high intake of red meat, and cigarette smoking. Sushi and wine intake are not risk factors for pancreatic cancer.

Assess for pallor or cyanosis. Check capillary refill. Try again to arouse her. Auscultate for bowel sounds. If she has a Foley catheter, check the urine volume and specific gravity.

p. 749, Safe and Effective Care Environment Which change in laboratory value or clinical manifestations in a client with hypovolemic shock indicates to the nurse that current therapy may need to be changed? A. Urine output increases from 5 mL/hour to 6 mL/hour B. Pulse pressure decreases from 28 mm Hg to 22 mm Hg C. Serum potassium level increases from 3.6 mEq/L to 3.9 mEq/L D. Core body temperature increases from 98.2° F (36.8° C) to 98.8° F (37.1° C)

B Rationale: A compensatory response to shock is vasoconstriction. Initially, the diastolic pressure increases but systolic pressure remains the same. As a result, the difference between the systolic and diastolic pressures (pulse pressure), is smaller or "narrower." When interventions are inadequate and shock worsens, systolic pressure decreases as cardiac output decreases. This causes the pulse pressure to narrow even further, indicating that shock is progressing. Although an increase in urine output usually signals improvement, a change of 1 mL/hr is within the margin of measurement error and is meaningless in this situation.

Iggy ch.59 p. 1218 The nurse is providing discharge instructions for a client who has undergone a laparoscopic cholecystectomy. Which instruction will the nurse include in the discharge teaching? A. Keep dressings in place for 4 weeks. B. Report bile-colored drainage from any of the incisions. C. Expect dark, tarry stools after surgery. D. Be aware that no dietary changes will be necessary.

B Rationale: Clients who undergo laparoscopic cholecystectomy usually only have one or a few small incisions that are covered with Steri-Strips and small adhesive bandages (e.g., Band-Aids). Bile-colored drainage should be reported immediately because this is not normal. The patient should not expect dark, tarry stools after surgery. Dietary changes should include avoidance of fatty foods.

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

Based on the degree of liver involvement and decreased function, protein intake may have to be decreased. However, some protein is necessary for the synthesis of albumin and normal healing. The other statements indicate accurate understanding of self-care measures for this client

p. 118, Safe and Effective Care Environment A trauma client has been brought to the emergency department after a motor vehicle crash. The client has severe injuries. What action does the nurse perform first? A. Start 2 large-bore IVs and run normal saline. B. Apply oxygen and an oximeter probe to the client. C. Stabilize the cervical spine and assess the airway. D. Place pressure on a large bleeding wound to the forehead.

C Establishing an airway is always the priority in a client with major trauma. The other interventions are done after the airway is established and patent.

p. 746, Physiological Integrity Which manifestations of shock are a result of compensatory mechanisms to maintain circulating blood volume? A. Edema and weight gain B. Confusion and lethargy C. Decreased urine output and thirst D. Increased pulse and respiratory rates

C Rationale: Both reduced urine output and thirst are stimulated by a decreasing circulating blood volume. When people can respond to thirst by drinking, the action compensates temporarily by increasing circulating fluid volume. Decreased or absent urine output compensates by preventing a greater fluid loss. The fluid that would have been lost from the body as urine is retained. This is why hourly urine output measurements are such a sensitive indicator for whether shock is improving or progressing. Edema and weight gain are not compensations for circulating blood volume. Confusion and lethargy are responses to circulating blood volume, not compensation to improve it. Increasing pulse and respiratory rates compensate for hypoxia, not for reduced volume.

p. 754, Patient-Centered Care; Evidence-Based Practice; Safety The patient is a 70-year-old man undergoing chemotherapy for lymphoma who was brought to the hospital by his wife because he was confused. His vital signs are: T = 95.7° F (35.4° C); P = 112; R = 28; BP = 96/50; SpO2 = 84%. His health history includes type 2 diabetes, a myocardial infarction 10 years ago (he now has an "on-demand" pacemaker), and hypertension. In addition to chemotherapy, his current oral medications include metformin (Glucophage) 850 mg twice daily, losartan (Cozaar) 50 mg daily, and aspirin 81 mg daily. When you ask whether there have been any changes lately, the wife tells you that he had a "touch" of fungal pneumonia 6 weeks ago and still has a cough with sputum. He has been very uncomfortable for the past week with a "boil" near his rectum. When you assess his perianal region, you find a large raised red bump with an open area draining purulent fluid. 4. Which intervention do you perform first and why?

Call the pharmacy immediately and get them working on the antibiotic order. It is important to get the antibiotic therapy started quickly. Before that arrives, perform the cultures (except for urine) and send them to the laboratory. Identifying the source of the infection and identifying the antibiotic(s) to which it is susceptible is critical for sepsis management. Draw the blood for the ordered laboratory work.

Clinical Judgment Challenge p. 1335, Prioritization, Delegation, and Supervision The patient, a 21-year-old college student, was brought to the emergency department (ED) by his roommate. He reports abdominal pain, polyuria for the past 2 days, vomiting several times prior to arrival, and extreme thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He demonstrates deep rapid respirations; there is a fruit odor to his breath. He has type 1 diabetes and "may have skipped a few doses of insulin because of cramming for final exams." He is alert and talking but is having trouble focusing on your questions. Blood pressure 110/60 Pulse 110/min Respirations 32/min Temperature 100.8F Fingerstick glucose 485 mg/dL Oxygen saturation 99% 1. You have completed triage assessment and history, should you now notify his parents for permission to treat him? Why or why not?

Calling the parents is not necessary because as the patient is old enough to sign consent for himself. (If he were under age, the treatment would not be delayed if the parents were unavailable in an emergency situation.) Calling the primary health care provider is usually done by the ED physician after the preliminary workup is completed. (Policies for calling private physicians may vary among institutions. Be sure to check the policy at your facility.)

Clinical Judgment Challenge p. 1335, Prioritization, Delegation, and Supervision The patient, a 21-year-old college student, was brought to the emergency department (ED) by his roommate. He reports abdominal pain, polyuria for the past 2 days, vomiting several times prior to arrival, and extreme thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He demonstrates deep rapid respirations; there is a fruit odor to his breath. He has type 1 diabetes and "may have skipped a few doses of insulin because of cramming for final exams." He is alert and talking but is having trouble focusing on your questions. Blood pressure 110/60 Pulse 110/min Respirations 32/min Temperature 100.8F Fingerstick glucose 485 mg/dL Oxygen saturation 99% 3. Should you call his primary health provider? Why or why not?

Calling the primary health care provider is usually done by the ED physician after the preliminary work-up is completed and interventions have started. (Policies for calling private physicians may vary among institutions. Be sure to check the policy at your facility.)

The Patient with Septic Shock A 72-year-old male patient has been living in an assited-living facility. He is generally alert, cheerful, and ambulatory with a walker. He has had frequent bouts of urinary tract infactions secondary to prostate problems and is being treated for high blood pressure. He was discovered today by one of the unlicensed assistive personnel (IAPs) in his room in a lethargic and confused state. He was easily aroused, but irritable and uncooperative with simple commands. He is transported to the emergency department (ED) for an acute change in mental status. On arrival to the ED, vital signs are: blood pressure, 110/70 mm Hg; pulse, 120 beats/min; respirations, 30 breaths/min; and temperature, 101F (38.3C). 2. Explain why a patient in severe septic shock could "look" better and have a warm, flushed appearance?

Cardiac function is hyperdynamic in this phase. The pooling of blood and the widespread capillary leak stimulate the heart, and cardiac output is increased with a more rapid heart rate and an elevated systolic blood pressure. In addition, the patient's extremities may feel warm and there is little or no cyanosis. Even though the patient may "look" better, the pathologic changes occurring at the tissue level are serious.

p. 753, Safe and Effective Care Environment Which clinical manifestation in a client alerts the nurse to the probability of septic shock instead of hypovolemic shock? A. Hypotension B. Pale, clammy skin C. Decreased urine output D. Oozing of blood at the IV site

D Rationale: The manifestations of hypotension, pale and clammy skin, and decreased urine output are associated with any type of shock, including hypovolemic shock and septic shock. Sepsis and septic shock, however, are associated with disseminated intravascular coagulation, which consumes clotting factors and leaves the client at high risk for hemorrhage. One of the earliest manifestations of septic shock is bleeding from any area of nonintact skin, including IV insertion sites.

p. 109, Safety The emergency department manager has created a task force to decrease the rate of adverse incidents in patients who have increased safety needs during their stay in the department. At their meeting, each person discussed a specific safety need and actions that can be taken to reduce that risk. 2. What specific procedures can the unit implement to decrease medication errors?

Decrease interruptions while obtaining and dispensing medications, ensure using two methods of identification before giving medications, always ask about allergies before giving any medication, and use standard policy for identifying unconscious people or those who do not have identification.

Clinical Judgment Challenges IGGY Ch64 p. 1329, Patient-Centered Care During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL, and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that he won't have all the diabetes complications that his father had. He further tells you that he did have his eyes checked by an optometrist to make sure his prescription was accurate but that because he was younger than 40 years old, he does not need intraocular pressure measurements. 3. Is he correct in thinking that an ophthalmologist visit is not necessary at this time? Explain your response.

Even if he did not have a vision problem, his risk for ophthalmic complications leading to blindness is high. Just having diabetes is a reason to been seen by an ophthalmologist rather than an optometrist (who is not a medical doctor). Depending on the control of his disease (which right now is not very controlled), coupled with long-standing vision problems, he should be seen yearly by an ophthalmologist. The ophthalmologist can determine whether a less frequent evaluation cycle would be appropriate.

Given that she has CHF, she will likely experience severe dyspnea and fatigue that will worsen over time.

Clinical Judgment Challenges IGGY Ch64 p. 1329, Patient-Centered Care During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL, and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that he won't have all the diabetes complications that his father had. He further tells you that he did have his eyes checked by an optometrist to make sure his prescription was accurate but that because he was younger than 40 years old, he does not need intraocular pressure measurements. 4. Is he correct in believing that taking antidiabetic medication will prevent complications of diabetes? Explain your response.

He is not correct in his thinking. Diabetes is a complex disorder and can only be controlled with a combination of antidiabetic medications and life-style changes that include nutrition therapy, maintenance of a healthy weight, blood pressure control, blood lipid control, and physical activity. The drugs are only part of the management plan. The fact that he was diagnosed at an earlier age and is taking medications is helpful, but without proper management, the complications of diabetes will not even be delayed let alone prevented.

p. 754, Patient-Centered Care; Evidence-Based Practice; Safety The patient is a 70-year-old man undergoing chemotherapy for lymphoma who was brought to the hospital by his wife because he was confused. His vital signs are: T = 95.7° F (35.4° C); P = 112; R = 28; BP = 96/50; SpO2 = 84%. His health history includes type 2 diabetes, a myocardial infarction 10 years ago (he now has an "on-demand" pacemaker), and hypertension. In addition to chemotherapy, his current oral medications include metformin (Glucophage) 850 mg twice daily, losartan (Cozaar) 50 mg daily, and aspirin 81 mg daily. When you ask whether there have been any changes lately, the wife tells you that he had a "touch" of fungal pneumonia 6 weeks ago and still has a cough with sputum. He has been very uncomfortable for the past week with a "boil" near his rectum. When you assess his perianal region, you find a large raised red bump with an open area draining purulent fluid. 2. What stage of the sepsis spectrum is he at this time and why?

He meets the criteria for severe sepsis even without any laboratory data: • Temperature of 96.8° F (36° C) • Heart rate greater than 90 beats/min • Respiratory rate greater than 20 breaths/min • Low oxygen saturation

p. 109, Safety The emergency department manager has created a task force to decrease the rate of adverse incidents in patients who have increased safety needs during their stay in the department. At their meeting, each person discussed a specific safety need and actions that can be taken to reduce that risk. 1. What populations are at highest risk of safety compromise while in the ED?

Highest risk populations include older adults, confused patients, patients who were given pain medication or sedation, patients impaired by drug or alcohol use, those who are unconscious, and those with no identification. In addition any condition that can cause dizziness and fainting or lying in the same position can cause a safety risk. Invasive procedures can increase the patient's risk for infection.

Her condition is consistent with hypoglycemia, especially because she received insulin about an hour ago. Manifestations of hypoglycemia include weakness; difficulty thinking; confusion; sweating; and cool, pale skin, and manifestations of hyperglycemia include warm, moist skin and possible fruity breath odor. Hyperglycemia does not change level of consciousness until it is severe.

p. 95, Patient-Centered Care A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me." 5. How do you feel about the patient wanting rehospitalization for heart failure?

Her desire for rehospitalization should not be judged; however, some health professionals would criticize her for wanting to use acute care for a terminal illness. As nurses, we must respect the patient's decisions, preferences, and values.

Clinical Judgment Challenges IGGY Ch64 p. 1329, Patient-Centered Care During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL, and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that he won't have all the diabetes complications that his father had. He further tells you that he did have his eyes checked by an optometrist to make sure his prescription was accurate but that because he was younger than 40 years old, he does not need intraocular pressure measurements. 1. How should you interpret his laboratory values in terms of his personal glucose regulation?

His fasting blood glucose level is acceptable and indicates that he has controlled his diabetes during the past 24 hours. However, his hemoglobin A1C is high, indicating that his overall control for the past several months is poor. It is possible that the current medication regimen is not sufficient to manage his disease. The fact that his weight is increasing rather than decreasing and that his blood lipid levels are quite high hint that his nutrition therapy is probably not being followed.

p. 747, Patient-Centered Care; Evidence-Based Practice; Safety Your patient is a 40-year-old woman who is returned to your ambulatory care unit after having a cholecystectomy (gall bladder removal) performed as minimally invasive surgery by laparoscopy. After moving her from the stretcher to her bed, you take her vital signs. Her pulse is 118 and thready, blood pressure is 88/72, respiratory rate is 28, and pulse oxymetry is 88%. When you call her name, she opens her eyes but does not answer any questions. 6. She still has an IV line in her left hand infusing dextrose 5% in 0.45% saline. The postsurgical orders indicate that it should be removed when she is stable. Should you remove it now? Why or why not?

If you think there is any possibility of shock, do not remove the IV line. It may be needed to give fluids, blood products, or drugs. If the patient is really experiencing shock, starting a new IV line would be difficult as venous pressure decreases.

Clinical Judgment Challenge p. 1335, Prioritization, Delegation, and Supervision The patient, a 21-year-old college student, was brought to the emergency department (ED) by his roommate. He reports abdominal pain, polyuria for the past 2 days, vomiting several times prior to arrival, and extreme thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He demonstrates deep rapid respirations; there is a fruit odor to his breath. He has type 1 diabetes and "may have skipped a few doses of insulin because of cramming for final exams." He is alert and talking but is having trouble focusing on your questions. Blood pressure 110/60 Pulse 110/min Respirations 32/min Temperature 100.8F Fingerstick glucose 485 mg/dL Oxygen saturation 99% 6. What intravenous (IV) solution do you anticipate the ED physician will order for initial fluid replacement?

Normal saline (0.9% sodium chloride) is the first fluid used to correct dehydration in most adults with diabetic ketoacidosis.

Clinical Judgment Challenge p. 1335, Prioritization, Delegation, and Supervision The patient, a 21-year-old college student, was brought to the emergency department (ED) by his roommate. He reports abdominal pain, polyuria for the past 2 days, vomiting several times prior to arrival, and extreme thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He demonstrates deep rapid respirations; there is a fruit odor to his breath. He has type 1 diabetes and "may have skipped a few doses of insulin because of cramming for final exams." He is alert and talking but is having trouble focusing on your questions. Blood pressure 110/60 Pulse 110/min Respirations 32/min Temperature 100.8F Fingerstick glucose 485 mg/dL Oxygen saturation 99% 2. Should you apply oxygen at this time? Why or why not?

Oxygen is not needed. Although his respiratory rate is above normal, he is not hypoxemic. Applying oxygen would serve no useful purpose.

A nurse cares for a client who is recovering from an open Whipple procedure. Which action should the nurse take? a. Clamp the nasogastric tube. b. Place the client in semi-Fowler's position. c. Assess vital signs once every shift. d. Provide oral rehydration.

Postoperative care for a client recovering from an open Whipple procedure should include placing the client in a semi-Fowler's position to reduce tension on the suture line and anastomosis sites, setting the nasogastric tube to low suction to remove free air buildup and pressure, assessing vital signs frequently to assess fluid and electrolyte complications, and providing intravenous fluids.

The Patient with Hypovolemic Shock A 38-year-old female patient returned to the postanesthesia recovery unit (PACU) 2 hours ago after undergoing a tubal ligation by colposcopy (through the back wall of the vagina behind the cervix). Her last documented vital signs, taken 30 minutes ago, were blood pressure, 102/80 mm Hg, pulse, 88 Beats/min, and respirations, 22 beats/min. The nurse now notes that her face is pale and the skin around her lips has a bluish cast. she reports some back pain. Her vital signs are now blood pressure, 90.76 mm Hg, pulse, 98 beats/min, and respirations, 28 breaths/min. 1. What additional assessment data would the nurse want to obtain?

Pulse oximetry for oxygen saturation: capillary refill; abdominal assessment (girth, bowel sounds, symmetry, evidence of bruising); palpation for consistency and subjective signs of tenderness or pain; any obvious signs of bleeding; change of mental status from baseline

Refer to the chart to compare these current vital signs to those obtained before and during surgery and in the postanesthesia recovery unit (PACU) to determine if the current vital signs represent a change. It is possible that the blood pressure is within the normal range for her. Also determine what type of anesthesia and drugs she received before and during surgery. Some drugs lower blood pressure. Spinal or epidural anesthesia can cause profound blood vessel dilation, leading to neurogenic shock rather than hypovolemic shock.

p. 109, Safety The emergency department manager has created a task force to decrease the rate of adverse incidents in patients who have increased safety needs during their stay in the department. At their meeting, each person discussed a specific safety need and actions that can be taken to reduce that risk. 4. How can the staff reduce hazard risks for patients who are confused (either as a chronic condition or as the result of medication side effects) or who have delirium?

Reorient the patient as needed, provide a calm, quiet environment and have family or familiar person sit at the bedside; if no family is available, provide a sitter. Use the smallest dose of medication needed to control symptoms, reassure the patient that he or she is safe, allow the patient to sit in a chair as tolerated, provide food and fluids if allowed, keep the patient warm, and meet other needs that might lead to patient trying to get up. Keep the siderails up and the call light in reach.

The Patient with Septic Shock A 72-year-old male patient has been living in an assited-living facility. He is generally alert, cheerful, and ambulatory with a walker. He has had frequent bouts of urinary tract infactions secondary to prostate problems and is being treated for high blood pressure. He was discovered today by one of the unlicensed assistive personnel (IAPs) in his room in a lethargic and confused state. He was easily aroused, but irritable and uncooperative with simple commands. He is transported to the emergency department (ED) for an acute change in mental status. On arrival to the ED, vital signs are: blood pressure, 110/70 mm Hg; pulse, 120 beats/min; respirations, 30 breaths/min; and temperature, 101F (38.3C). 1. What does the term SIRS stand for? Discuss how this patient meets or does not meet the criteria for SIRS. If the patient meets the criteria, what additional assessments and diagnostic tests should be performed?

SIRS stands for systemic inflammatory response syndrome. This patient is exhibiting a hypodynamic state and decreased cardiac output as evidenced by his increased heart rate, increased respiratory rate, fever, lethargy, and confusion. The patient will need evaluation of urine output, and laboratory work to identify the source of infection.

p. 747, Patient-Centered Care; Evidence-Based Practice; Safety Your patient is a 40-year-old woman who is returned to your ambulatory care unit after having a cholecystectomy (gall bladder removal) performed as minimally invasive surgery by laparoscopy. After moving her from the stretcher to her bed, you take her vital signs. Her pulse is 118 and thready, blood pressure is 88/72, respiratory rate is 28, and pulse oxymetry is 88%. When you call her name, she opens her eyes but does not answer any questions. 3. How would you classify this stage of shock? Provide a rationale for your evaluation.

She is most likely in the nonprogressive stage of shock. Her pulse pressure is quite narrow. Her oxygen saturation is lower than normal for her age and health. The fact that she is not responding to questions suggests the nonprogressive stage rather than the initial stage. Because we do not know her usual blood pressure, we cannot establish the shock stage on that basis.

The Patient with Hypovolemic Shock A 38-year-old female patient returned to the postanesthesia recovery unit (PACU) 2 hours ago after undergoing a tubal ligation by colposcopy (through the back wall of the vagina behind the cervix). Her last documented vital signs, taken 30 minutes ago, were blood pressure, 102/80 mm Hg, pulse, 88 Beats/min, and respirations, 22 beats/min. The nurse now notes that her face is pale and the skin around her lips has a bluish cast. she reports some back pain. Her vital signs are now blood pressure, 90.76 mm Hg, pulse, 98 beats/min, and respirations, 28 breaths/min. 3. Given these findings, which actions would be priority actions for the nurse?

Start oxygen administration by mask. Alert the Rapid Response Team. Notify the health care provider of the findings. Check whether the IV line is patent - it it is patent, infuse fluid at 100 mL/hr. If it is not patent, or if IV access is not in place, start an IV with 0.9% saline. If blood has not been types and cross-matched, draw and send a sample for at least 2 units of blood.

The Patient with Septic Shock A 72-year-old male patient has been living in an assited-living facility. He is generally alert, cheerful, and ambulatory with a walker. He has had frequent bouts of urinary tract infactions secondary to prostate problems and is being treated for high blood pressure. He was discovered today by one of the unlicensed assistive personnel (IAPs) in his room in a lethargic and confused state. He was easily aroused, but irritable and uncooperative with simple commands. He is transported to the emergency department (ED) for an acute change in mental status. On arrival to the ED, vital signs are: blood pressure, 110/70 mm Hg; pulse, 120 beats/min; respirations, 30 breaths/min; and temperature, 101F (38.3C). 3. Explain why the patient can have a massive infection with a low white blood cell (WBC) count.

The WBC count at this time may no longer be elevated because a prolonged early sepsis stage may have worn out the bone marrow's ability to keep producing and releasing new mature neutrophils and other WBCs.

The patient should receive more education about the relationship between insulin and eating. The unit needs to establish guidelines or policies about premeal insulin administration. Perhaps it should not be administered until the tray is actually in the patient's possession and the patient is ready to eat it. Also, whenever short-acting insulin is given, the nurse giving it should evaluate the patient within 20 minutes.

Clinical Judgment Challenges IGGY Ch64 p. 1329, Patient-Centered Care During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL, and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that he won't have all the diabetes complications that his father had. He further tells you that he did have his eyes checked by an optometrist to make sure his prescription was accurate but that because he was younger than 40 years old, he does not need intraocular pressure measurements. 5. How do you propose to assist this patient in managing his diabetes?

The patient's comments and the laboratory data indicate that he does not understand the disease, its consequences, management techniques, and his role in the management plan. His issues are going to require more than your intervention, although you can get this started. Patient-centered evaluation and management with the entire diabetes management team is needed as soon as possible. He will need further testing to assess for early-stage complications and possible changes to his medication regimen. You should start by asking what he knows about the disease and correct any misunderstandings. Bringing in a diabetes educator, the health care provider and registered dietitian is really needed now. If classes are available, he should be strongly encouraged to start them. If he has a partner, try to include her or him in this process. Essentially, this patient requires that the team treat him as if he had just been newly diagnosed with diabetes.

p. 747, Patient-Centered Care; Evidence-Based Practice; Safety Your patient is a 40-year-old woman who is returned to your ambulatory care unit after having a cholecystectomy (gall bladder removal) performed as minimally invasive surgery by laparoscopy. After moving her from the stretcher to her bed, you take her vital signs. Her pulse is 118 and thready, blood pressure is 88/72, respiratory rate is 28, and pulse oxymetry is 88%. When you call her name, she opens her eyes but does not answer any questions. 5. Given the type of surgery she has undergone, where would you expect bleeding to occur, and what manifestations would indicate possible bleeding?

This surgery is performed with a one or two small incision through the abdominal wall. Although this is a small surface dressing, bleeding into the dressing is unlikely. If bleeding occurs within the surgical area of the abdomen, no external bleeding will be present. Bleeding into the abdominal cavity would cause some pain, increasing as the volume of blood in the cavity increases. Abdominal size, as measured by abdominal girth, would also increase. Skin discoloration on the lower abdomen or the lower back could be present if the volume of blood lost to the cavity is large.

Clinical Judgment Challenge p. 1335, Prioritization, Delegation, and Supervision The patient, a 21-year-old college student, was brought to the emergency department (ED) by his roommate. He reports abdominal pain, polyuria for the past 2 days, vomiting several times prior to arrival, and extreme thirst. He appears flushed, and his lips and mucous membranes are dry and cracked. His skin turgor is poor. He demonstrates deep rapid respirations; there is a fruit odor to his breath. He has type 1 diabetes and "may have skipped a few doses of insulin because of cramming for final exams." He is alert and talking but is having trouble focusing on your questions. Blood pressure 110/60 Pulse 110/min Respirations 32/min Temperature 100.8F Fingerstick glucose 485 mg/dL Oxygen saturation 99% 4. Your work plan includes checking hourly vital signs, assessing blood glucose levels, updating the roommate about the patient's condition, and measuring the patient's emesis. Which task(s) is (are) appropriate to assign to the new nursing assistant? Provide a rationale for your choices.

Vital signs and measuring and recording output are within the scope of duties for the nursing assistant. Releasing information should not be done by the nursing assistant because of confidentiality issues. The RN should decide how to convey information to friends and family who are waiting keeping HIPAA standards in mind. Checking blood glucose is usually accomplished with a fingerstick, which is usually within the scope of practice for the experienced nursing assistant but not for one who is new.

80. The nurse is caring for a diabetic patient in the ED. The patient's lab values include serum glucose 353 mg/dL, positive serum ketones, and positive urine ketones. What complication does the nurse suspect? a. DKA b. HHS c. Hyperglycemia d. Hypoglycemia

56. What type of exercise does the nurse recommend for the patient with diabetic retinopathy? a. Non-weight-bearing activities such as swimming b. Weight-bearing activities such as jogging c. Vigorous aerobic and resistance exercises d. Weight training and heavy lifting

72. Which diabetic patient is at greatest risk for diabetic foot ulcer formation? a. 75-year-old African male with history of cardiovascular disease b. 53-year-old Caucasian female with history of renal insufficiency c. 38-year-old American Indian with history of gastric ulcers d. 28-year-old Caucasian male with history of chronic kidney disease

While hemorrhage could occur anywhere, the most obvious areas to examine include the perineal area for vaginal bleeding, under the patient, and the IV site. Also look for petechiae on the chest. Considering that her surgery was performed with a scope instrument without an external incision, hemorrhage is most likely to be internal in this situation. The patient's report of back pain is consistent with internal hemorrhage. The nurse reaseesses the patient 15 minutes later. Vital signs are blood pressure, 88/70 mm Hg, pulse, 102 beats/min, and respirations, 30 breaths/min. She awakens when the nurse shakes her arm and reports increased back pain and thirst.

p. 754, Patient-Centered Care; Evidence-Based Practice; Safety The patient is a 70-year-old man undergoing chemotherapy for lymphoma who was brought to the hospital by his wife because he was confused. His vital signs are: T = 95.7° F (35.4° C); P = 112; R = 28; BP = 96/50; SpO2 = 84%. His health history includes type 2 diabetes, a myocardial infarction 10 years ago (he now has an "on-demand" pacemaker), and hypertension. In addition to chemotherapy, his current oral medications include metformin (Glucophage) 850 mg twice daily, losartan (Cozaar) 50 mg daily, and aspirin 81 mg daily. When you ask whether there have been any changes lately, the wife tells you that he had a "touch" of fungal pneumonia 6 weeks ago and still has a cough with sputum. He has been very uncomfortable for the past week with a "boil" near his rectum. When you assess his perianal region, you find a large raised red bump with an open area draining purulent fluid. 3. Should you apply oxygen to him before he is seen by the health care provider? Why or why not?

Yes, apply oxygen. He is hypoxic and some tissues are operating under anaerobic metabolism, which will lead to greater tissue damage earlier.

Clinical Judgment Challenges IGGY Ch64 p. 1329, Patient-Centered Care During a clinic visit, you are reviewing the records of a 39-year-old patient who was diagnosed 5 years ago with type 2 diabetes. You discover that, although he has always been extremely near-sighted, he has not seen an ophthalmologist for 4 years. He has gained 12 lbs since his last visit a year ago. His laboratory values show a fasting blood glucose level of 96 mg/dL, an A1C of 8.2%, a total cholesterol of 322 mg/dL, and an LDL of 190 mg/dL. When you ask him about ophthalmology follow-up and point out his laboratory values, he replies that because he is taking prescribed antidiabetic medication, he believes that he won't have all the diabetes complications that his father had. He further tells you that he did have his eyes checked by an optometrist to make sure his prescription was accurate but that because he was younger than 40 years old, he does not need intraocular pressure measurements. 2. Should you address his weight gain? Why or why not?

Yes, you should address his weight. A major pathophysiological problem with type 2 diabetes is insulin resistance. Increasing weight correlates to greater insulin resistance. Even modest weight loss can improve the sensitivity of insulin receptors to insulin. The excess weight is contributing even more to his risk for cardiovascular events, as evidenced by the high blood lipid levels.

64. The nurse is caring for a patient with DM. The patient's urine is positive for ketones. What does the nurse instruct the patient with regard to exercise? a. "When urine ketones are present, you should not exercise." b. "You may exercise as long as serum ketones are negative." c. "If you exercise now, be sure to perform aerobic exercise." d. "Exercise is always a good option because it helps with glucose utilization."

p. 95, Patient-Centered Care A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me." 2. What types of referral might you make for her? How would you do this?

You might refer her to a social worker if she is willing to talk with someone about advance directives. Check with your agency to determine how consults or referrals are made.

p. 95, Patient-Centered Care A 77-year-old female with stage IV heart failure has had two hospitalizations for congestive heart failure (CHF) exacerbations in the past month. The patient lives alone and has no durable power of attorney for health care or living will. She tells you she does not need an advance directive because she "can just come back to the hospital and they will take care of me." 1. How would you respond to the patient at this time?

You need to teach her about what advance directives are and why everyone needs one. Explain to her what might happen to her without an advance directive if she becomes seriously ill and health decisions are needed.

The Patient with Septic Shock A 72-year-old male patient has been living in an assited-living facility. He is generally alert, cheerful, and ambulatory with a walker. He has had frequent bouts of urinary tract infactions secondary to prostate problems and is being treated for high blood pressure. He was discovered today by one of the unlicensed assistive personnel (IAPs) in his room in a lethargic and confused state. He was easily aroused, but irritable and uncooperative with simple commands. He is transported to the emergency department (ED) for an acute change in mental status. On arrival to the ED, vital signs are: blood pressure, 110/70 mm Hg; pulse, 120 beats/min; respirations, 30 breaths/min; and temperature, 101F (38.3C). 5. The patient recovers and is discharged back to the assisted-living facility. What types of information would the hospital nurse give to the nurse at the assisted-living facility regarding the patient? Use the SBAR format to document this hand-off report.

[s]ituation: 72-year-old male patient was transported to the ED for acute change in mental status. [b]ackground: The patient was discovered in his room of his assisted-living facility in a lethargic and confused state by one of UAPs. He was easily aroused but irritable and uncooperative with simple commands. He has had frequent bouts of urinary tract infections secondary to prostate problems and is being treated for high blood pressure. He is generally alert, cheerful, and ambulatory with a walker. [a]ssessment: On arrival to the ED, vital signs are 110/70 mm Hg, pulse 120 beats/min, respirations 30/min, and temperature 101F (38.3C). [r]ecommendation: Discharge instructions to be given to the patient and family.

The Patient with Hypovolemic Shock A 38-year-old female patient returned to the postanesthesia recovery unit (PACU) 2 hours ago after undergoing a tubal ligation by colposcopy (through the back wall of the vagina behind the cervix). Her last documented vital signs, taken 30 minutes ago, were blood pressure, 102/80 mm Hg, pulse, 88 Beats/min, and respirations, 22 beats/min. The nurse now notes that her face is pale and the skin around her lips has a bluish cast. she reports some back pain. Her vital signs are now blood pressure, 90.76 mm Hg, pulse, 98 beats/min, and respirations, 28 breaths/min. 5. The primary health care provider has arrived in the PACU. Document the SBAR report that the nurse would give in the hand-off.

[s]ituation: This 38-year-old female patient returned to the postanesthesia recovery area 2 hours ago after undergoing a tubal ligation by colposcopy. [b]ackground: Initial vital signs taken on returning to the postanesthesia recovery area were blood pressure 102/80 mm Hg, pulse 88 beasts/min, and respirations 22/min. Her vital signs assessed 30 minutes later were blood pressure 90/76 mm Hg, pulse 98 beats/min, and respirations 28/min. The patient's face was pale and the skin around her lips had a bluish cast. She also reported back pain of a 3 on a 0-10 scale. At that thime the patient was assessed for oxygen saturation and signs of bleeding. [a}ssessment: At this time her VS are blood pressure 88/70 mm Hg, pulse 102 beats/min, and respirations 30/min. The patient has awakened and reports increased back pain and thirst. [r]ecommendation: The nurse recommends increased IV fluids and for the patient to return to the OR for further assessment of location if internal bleeding.

10. The terminally ill patient is nearing death. His wife expresses concern that he has no appetite and eats very little. What is the nurse's best response to this concern? a. Teach the patient's wife about the risk of aspiration and explain that loss of appetite is normal when a patient nears death. b. Encourage the patient's wife to feed the patient as much as he will take to maintain adequate nutrition. c. Request that the health care provider order a dietary nutrition consult to include foods that the patient prefers. d. Keep fluids and finger foods at the bedside for easy access whenever the patient is hungry or thirsty.

14. A patient is admitted with a blood glucose level of 900 mg/dL. IV fluids and insulin are administered. Two hours after treatment is initiated, the blood glucose level is 400 mg/dL. Which complication is the patient most at risk for developing? a. Hypoglycemia b. Pulmonary embolus c. Renal shutdown d. Pulmonary edema

15. The most common treatment of pain in a terminally ill patient is administration of which kind of therapy? a. Opioids b. Steroids c. Nonsteroidal antiinflammatory agents d. Radiation treatments

16. Assessment findings of a patient with trauma injuries reveal cool, pale skin; reported thirst, urine output 100 mL/8 hr, blood pressure 122/78 mm Hg, pulse 102 beats/min, respirations 24/min with decreased breath sounds. This patient is in what phase of shock? a. Compensatory/nonpgrogressive b. Progressive c. Refractory d. Multiple organ dysfunction

17. The patient is both confused and agitated. Which action is most important at this time? a. Place the patient in a quiet supervised area. b. Check the patient every 2 hours. c. Sedate the patient using IV medication . d. Turn on the television to keep the patient's attention.

21. A patient with a hypophysectomy can postoperatively experience transient DI. Which manifestation alerts the nurse to this problem? a. Output much greater than intake b. Change in mental status indicating confusion c. Laboratory results indicating hyponatremia d. Nonpitting edema

22. Which patient is most likely to show elevated hemoglobin and hematocrit during shock? a. Patient with severe vomiting and large amounts of watery diarrheal stools b. Patient with a large wound with copious drainage c. Patient who was stable after surgery, but is now decompensating d. Patient with a hemothorax and chest tube

23. A diabetic patient is scheduled to have a blood glucose tests the next morning. What does the nurse tell the patient to do before coming in for the test? a. Eat the usual diet but have nothing after midnight. b. Take the usual oral hypoglycemic tablet in the morning. c. Eat a clear liquid breakfast in the morning. d. Follow the usual diet and medication regimen.

24. A patient is at risk for hypovolemia secondary to large amounts of watery diarrhea and vomiting. The patient reports feeling a little thirsty and a slightly lightheaded. What does the nurse do next? a. Take the blood pressure and pulse and compare results to the patient's baseline. b. Obtain an order to start a sodium nitroprusside (Nipride) IV infusion. c. Have the patient rest in bed and take small frequent sips of water. d. Compare the patient's intake to the urinary output.

31. For which patient should the health care provider avoid prescribing rosiglitazone (Avandia)? a. Patient with symptomatic heart failure b. Patient with new-onset asthma c. Patient with kidney disease d. Patient with hyperthyroidism

31. Which change in the skin is an early indication of hypovolemic shock? a. Pallor or cyanosis in the mucous membranes. b. Color changes in the trunk area c. Axilla and groin feel moist or clammy d. Generalized mottling of skin

33. Which nursing intervention is the priority for a patient with SIADH? a. Restrict fluid intake. b. Monitor neurologic status at least every 2 hours. c. Offer ice chips frequently to ease discomfort by dry mouth . d. Monitor urine tests for decreased sodium levels and low specific gravity.

36. A patient asks the nurse how insulin injection site rotation should be accomplished. What is the nurse's best response? a. "Rotation with one site is preferred to avoid changes in insulin absorption." b. "Change rotation sites after a week or two to avoid lipohypertrophy." c. "Rotation from site to site each day is best for the best insulin absorption." d. "Always rotate insulin injection sites within 4 to 5 inches from the umbilicus."

55. An ACTH stimulation test is the most definitive test for which disorder? a. Adrenal insufficiency b. Cushing's syndrome c. Pheochromocytoma d. Acromegaly

56. What factor increases an older adult's risk for distributive (septic) shock? a. Reduced skin integrity b. Diuretic therapy c. Cardiomyopathy d. Musculoskeletal weakness

Iggy Study Guide Ch.59 10. The nurse is administering ketorolac (Toradol) to a 78-year-old patient for mild to moderate pain management. Which assessment finding indicates the patient is experiencing a side effect of this drug? a. Abdominal bloating and cramping b. Ventricular cardiac dysrhythmias c. Decreased urinary output d. Jaundice

Iggy Study Guide Ch.59 12. Which factor renders a patient the least likely to benefit from ESWL for the treatment of gallstones? a. Height 5 feet 10 inches, 325 lbs. b. Cholesterol-based stones. c. Height 5 feet 7 inches, 138 lbs. d. Small gallstones

Iggy Study Guide Ch.59 4. The nurse on a medical-surgical unit is caring for several patients with acute cholecystitis. Which task is best to delegate to the unlicensed assistive personnel (UAP)? a. Obtain the patient's vital signs. b. Determine if any foods are not tolerated. c. Assess what measures relieve the abdominal pain. d. Ask the patients to describe their daily acitivity or exercise routines.

Question 5 of 26 The nurse working on an inpatient hospice unit has received the change-of-shift report. Which client does the nurse assess first? a. A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety b. A 30-year-old with AIDS-associated dementia and agitation who is asking for assistance with calling family members c. A 62-year-old with lung cancer who has cool, clammy, dusky skin and blood pressure of 64/20 mm Hg d. A 70-year-old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations

a A 26-year-old with metastatic breast cancer who is experiencing pain rated at 10 (0-to-10 scale) and anxiety Management of discomfort is the priority goal for hospice care, so decreasing this client's pain and anxiety should be the first action. The client with AIDS needs rapid assistance, but is the second priority for the nurse in this scenario. The client with lung cancer and the client with colon cancer are exhibiting normal signs and symptoms associated with dying.

Question 24 of 26 A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem action does the nurse implement? a. Asks the family if they wish to help wash the client b. Asks the family to leave c. Raises the head of the bed and opens the client's eyes d. Removes dentures and any prosthetics

a Asks the family if they wish to help wash the client The nurse may ask the family if they wish to be involved in washing the client after the client's death. The family should be allowed to grieve at the bedside of the client. The head of the bed should be flat and the client's eyes closed. The client's dentures and prosthetics should be replaced, not removed.

Question 2 of 10 A client comes into the emergency department (ED) clutching the chest. Which core competency for ED nurses is the first one used in this situation? a. Assessment b. Communication c. Priority setting d. Technical and procedural skills

a Assessment Similar to any nurse in practice, the foundation of the emergency nurse's skill base is assessment. The nurse must be able to discern normal from abnormal rapidly and accurately, and must interpret assessment findings according to acuity and age. Communication, priority setting, and technical and procedural skills are not the first competencies to be used in this situation.

18. The nurse has just received change-of-shift report on the endocrine unit. Which client does the nurse see first? a. Client with type 1 diabetes whose insulin pump is beeping "occlusion" b. Newly diagnosed client with type 1 diabetes who is reporting thirst c. Client with type 2 diabetes who has a blood glucose of 150 mg/dL d. Client with type 2 diabetes with a blood pressure of 150/90 mm Hg

a Because glucose levels will increase quickly in clients who use continuous insulin pumps, the nurse should assess this client and the insulin pump first to avoid diabetic ketoacidosis. Thirst is a symptom of hyperglycemia and, although important, is not a priority; the nurse could delegate a fingerstick blood glucose to unlicensed assistive personnel while assessing the client whose insulin pump is beeping. Although a blood glucose reading of 150 mg/dL is mildly elevated, this is not an emergency. Mild hypertension is also not an emergency.

Question 3 of 10 A client with a gunshot wound is admitted to the emergency department (ED). Which minimum Standard Precaution activity does the nurse require for staff safety? a. Blood and body fluid precautions b. Metal detector screening of the client c. Placement of a security guard d. Use of a positive air-purifying respirator (PAPR)

a Blood and body fluid precautions The ED nurse uses Standard Precautions at all times when there is the potential for contamination by blood or other body fluids. Screening of the client with a metal detector, appointing a security guard, and use of a PAPR, although beneficial, are not minimum Standard Precautions.

Review Questions - NCLEX® Examination - Chapter 37 Question 24 of 26 A client is admitted to the hospital with two of the systemic inflammatory response syndrome variables: temperature of 95° F (35° C) and high white blood cell count. Which intervention from the sepsis resuscitation bundle does the nurse initiate? a. Broad-spectrum antibiotics b. Blood transfusion c. Cooling baths d. NPO status

a Broad-spectrum antibiotics Broad-spectrum antibiotics must be initiated within 1 hour of establishing diagnosis. A blood transfusion is indicated for low red blood cell count or low hemoglobin and hematocrit; transfusion is not part of the sepsis resuscitation bundle. Cooling baths are not indicated because the client is hypothermic, nor is this part of the sepsis resuscitation bundle. NPO status is not indicated for this client, nor is it part of the sepsis resuscitation bundle.

Review Questions - NCLEX® Examination - Chapter 37 Question 18 of 26 The nursing assistant is concerned about a postoperative client with blood pressure (BP) of 90/60 mm Hg, heart rate of 80 beats/min, and respirations of 22 breaths/min. What does the supervising nurse do? a. Compare these vital signs with the last several readings. b. Request that the surgeon see the client. c. Increase the rate of intravenous fluids. d. Reassess vital signs using different equipment.

a Compare these vital signs with the last several readings. Vital sign trends must be taken into consideration; a BP of 90/60 mm Hg may be normal for this client. Calling the surgeon is not necessary at this point, and increasing IV fluids is not indicated. The same equipment should be used when vital signs are taken postoperatively.

Question 2 of 26 A hospitalized client of the Islamic (Muslim) religion is dying. What concept does the nurse share with the health care team about this client's beliefs about death? a. Death is seen as the transition to the other side, with Islam as the vehicle. b. Life experiences do not affect the individual's preparation for "everlasting life." c. The timing of death is under the power of the person who is facing death. d. Plans for burial will take days, maybe even weeks, after the death.

a Death is seen as the transition to the other side, with Islam as the vehicle. In the Muslim faith, Islam is the vehicle that transports the person to the "other side." This is a fundamental belief of the religion. Life is meant to be a test of preparation for everlasting life in the hereafter; life experiences do affect the person's afterlife existence. Muslims believe that God (Allah), rather than the person, has prescribed a time of death for everyone. Preparation for burial takes place as soon as possible after death has occurred.

5. A patient with a PRL-secreting tumor is likely to be treated with which medications? a. Dopamine agonists b. Vasopressin c. Steroids d. Growth hormone (GH)

a Dopamine agonists

Review Questions - NCLEX® Examination - Chapter 37 Question 3 of 26 The client with which problem is at highest risk for hypovolemic shock? a. Esophageal varices b. Kidney failure c. Arthritis and daily acetaminophen use d. Kidney stone

a Esophageal varices Esophageal varices are caused by portal hypertension; the portal vessels are under high pressure and are prone to rupture, causing massive upper gastrointestinal tract bleeding and hypovolemic shock. As the kidneys fail, fluid is typically retained, causing fluid volume excess, not hypovolemia. Nonsteroidal anti-inflammatory drugs such as naproxen and ibuprofen, not acetaminophen, predispose the client to gastrointestinal bleeding and hypovolemia. Although a kidney stone may cause hematuria, there is not generally massive blood loss or hypovolemia.

Question 3 of 26 A client diagnosed with lung cancer 6 months ago is now ventilator-dependent and unresponsive. The family wants to remove the ventilator and stop antibiotics and IV fluids. What does the nurse do next? a. Facilitates a meeting with the family and health care team b. Removes the interventions, per the family's wishes c. Tells the family that removing the interventions is illegal d. Waits to obtain information on the client's wishes

a Facilitates a meeting with the family and health care team Withdrawing or withholding life-sustaining therapy involves discontinuing one or more therapies that might prolong the life of a person who cannot be cured by the therapy. To do this, a meeting is required between the family and the health care team. Withdrawing life support requires more than simply following the family's wishes. Removal of life-sustaining therapy is not illegal except in cases of active euthanasia or physician-assisted euthanasia. The client most likely will not regain consciousness; the client's wishes should have been determined and documented earlier in the course of his or her disease (advance directives, living will, etc.).

21. The nurse is teaching a client with type 2 diabetes about the importance of weight control. Which comment by the client indicates a need for further teaching? a. "I should begin exercising for at least an hour a day." b. "I should monitor my diet." c. "If I lose weight, I may not need to use the insulin anymore." d. "Weight loss can be a sign of diabetic ketoacidosis."

a For long-term maintenance of major weight loss, large amounts of exercise (7 hr/wk) or moderate or vigorous aerobic physical activity may be helpful, but the client must start slowly. Monitoring the diet is key to type 2 diabetes management. Weight loss can minimize the need for insulin and can also be a sign of diabetic ketoacidosis.

Question 9 of 10 A client is admitted to the emergency department after reporting being raped. Who is the best team member for the admitting nurse to locate to provide care for this client? a. Forensic nurse examiner b. Physician or health care provider c. Psychiatric crisis nurse d. Police officer

a Forensic nurse examiner The forensic nurse examiner is trained to recognize evidence of abuse and to intervene on the client's behalf. Although the physician or health care provider, the psychiatric crisis nurse, and the police officer may be involved at some point in the care of this particular client, they are not the best individuals to collaborate with at this time. It is important to remember that not all rapes are required to be reported to the police.

Review Questions - NCLEX® Examination - Chapter 37 Question 5 of 26 The client with which laboratory result is at risk for hemorrhagic shock? a. International normalized ratio (INR) 7.9 b. Partial thromboplastin time (PTT) 12.5 seconds c. Platelets 170,000/mm3 d. Hemoglobin 8.2 g/dL

a International normalized ratio (INR) 7.9 Prolonged INR indicates that blood takes longer than normal to clot; this client is at risk for bleeding. PTT of 12.5 seconds and a platelet value of 170,000/mm3 are both normal and pose no risk for bleeding. Although a hemoglobin of 8.2 g/dL is low, the client could have severe iron deficiency or could have received medication affecting the bone marrow.

Question 7 of 10 An air medical helicopter arrives on the scene of a high-speed motorcycle collision with a train. The client was not wearing a helmet and is very confused, with a Glasgow Coma Scale score of 13. There is an apparent partial amputation of both hands. Vital signs are stable and the airway is secure. Which level of trauma center would be the most appropriate destination for this client? a. Level I b. Level II c. Level III d. Level IV

a Level I The American College of Surgeons defines a Level I trauma center as a regional resource facility capable of "providing leadership and total care for every aspect of injury, from prevention through rehabilitation." A Level II trauma center may not be able to meet the resource needs of clients who require very complex injury management, such as those in need of advanced surgical care. The primary focus of a Level III trauma center is injury stabilization and client transfer. In a Level IV trauma center, clients are stabilized to the best degree possible before transfer, with the use of available personnel. Resources, including the consistent availability of a physician, may be extremely limited.

Review Questions - NCLEX® Examination - Chapter 37 Question 22 of 26 The nurse reviews the medical record of a client with hemorrhagic shock, which contains the following information:Physical Assessment FindingsDiagnostic FindingsPulse 140 beats/min and threadyABG respiratory acidosisBlood pressure 60/40 mm HgLactate level 7 mOsm/LRespirations 40/min and shallow All of these provider prescriptions are given for the client. Which does the nurse carry out first? a. Notify anesthesia for endotracheal intubation. b. Give Plasmanate 1 unit now. c. Give normal saline solution 250 mL/hr. d. Type and crossmatch for 4 units of packed red blood cells (PRBCs).

a Notify anesthesia for endotracheal intubation. Establishing an airway is the priority in all emergency situations. Although administering Plasmanate and normal saline, and typing and crossmatching for 4 units of PRBCs are important actions, airway always takes priority.

17. The nurse caring for four diabetic clients has all of these activities to perform. Which is appropriate to delegate to unlicensed assistive personnel (UAP)? a. Perform hourly bedside blood glucose checks for a client with hyperglycemia. b. Verify the infusion rate on a continuous infusion insulin pump. c. Monitor a client with blood glucose of 68 mg/dL for tremors and irritability. d. Check on a client who is reporting palpitations and anxiety.

a Performing bedside glucose monitoring is an activity that may be delegated because it does not require extensive clinical judgment to perform; the nurse will follow up with the results. Intravenous therapy and medication administration are not within the scope of practice for UAP. The client with blood glucose of 68 mg/dL will need further monitoring, assessment, and intervention not within the scope of practice for UAP. The client reporting palpitations and anxiety may have hypoglycemia, requiring further intervention; this client must be assessed by licensed nursing staff.

NCLEX® Examination Challenges IGGY Ch.64 p. 1317, Health Promotion and Maintenance Which statement made by a client who is learning about self-injection of insulin indicates to the nurse that clarification is needed about injection site selection and rotation? A. "The abdominal site is best because it is closest to the pancreas." B. "I can reach my thigh best, so I will use different areas of the same thigh." C. "By rotating sites within one area, my chance of having skin changes is less." D. "If I change my injection site from the thigh to an arm, the inulin absorption may be different."

a Rationale: The abdominal site has the fastest and most consistent rate of absorption because of the blood vessels in the area, not because of its proximity to the pancreas.

20. The nurse is providing discharge teaching to a client with diabetes about injury prevention for peripheral neuropathy. Which statement by the client indicates a need for further teaching? a. "I can break in my shoes by wearing them all day." b. "I need to monitor my feet daily for blisters or skin breaks." c. "I should never go barefoot." d. "I should quit smoking."

a Shoes should be properly fitted and worn for a few hours a day to break them in, with frequent inspection for irritation or blistering. People with diabetes have decreased peripheral circulation, so even small injuries to the feet must be managed early. Going barefoot is contraindicated. Tobacco use further decreases peripheral circulation in a client with diabetes.

Review Questions - NCLEX® Examination - Chapter 37 Question 10 of 26 A client recovering from an open reduction of the femur suddenly feels light-headed, with increased anxiety and agitation. Which key vital sign differentiates a pulmonary embolism from early sepsis? a. Temperature b. Pulse c. Respiration d. Blood pressure

a Temperature A sign of early sepsis is low-grade fever. Both early sepsis and thrombus may cause tachycardia, tachypnea, and hypotension.

19. Which is the best referral that the nurse can suggest to a client who has been newly diagnosed with diabetes? a. American Diabetes Association b. Centers for Disease Control and Prevention c. Health care provider office d. Pharmaceutical representative

a The American Diabetes Association can provide national and regional support and resources to clients with diabetes and their families. The Centers for Disease Control and Prevention does not focus on diabetes. The client's health care provider's office is not the best resource for diabetes information and support. A pharmaceutical representative is not an appropriate resource for diabetes information and support.

8. A client with type 1 diabetes arrives in the emergency department breathing deeply and stating, "I can't catch my breath." The client's vital signs are: T 98.4° F (36.9° C), P 112 beats/min, R 38 breaths/min, BP 91/54 mm Hg, and O2 saturation 99% on room air. Which action does the nurse take first? a. Check the blood glucose. b. Administer oxygen. c. Offer reassurance. d. Attach a cardiac monitor.

a The client's clinical presentation is consistent with diabetic ketoacidosis, so the nurse should initially check the client's glucose level. Based on the oxygen saturation, oxygen administration is not necessary. The nurse provides support, but it is early in the course of assessment and intervention to offer reassurance without more information. Cardiac monitoring may be implemented, but the first action should be to obtain the glucose level.

12. The nursing student takes the morning blood pressure of a postoperative patient and the reading is 90/50 mm Hg. What does the student do next? (Select all that apply.) a. Report the reading to the primary nurse as a possible sign of hypovolemia. b. Assess the patient for subjective feelings of dizziness or shortness of breath. c. Check the patient's chart for trends of morning vital sign readings. d. Notify the instructor to verify the significance of the finding. e. Call a "code blue."

a, b, c, d

17. Following a hypophysectomy, the patient requires instruction on hormone replacement for which hormones? (Select all that apply.) a. Cortisol b. Thyroid c. Gonadal d. Vasopressin e. PRL

a, b, c, d

26. A hospital patient is prescribed desmopressin acetate metered dose spray as a replacement hormone for ADH. Which is an indication for another dose? (Select all that apply.) a. Excessive urination b. Specific gravity of 1.003 c. Dark, concentrated urine d. Edema in the legs e. Decreased urination

a, b

25. A patient with hypovolemia is restless and anxious. The skin is cool and pale, pulse is thready at a rate of 135 beats/min; blood pressure is 92/50 mm Hg; respirations are 32/min. What actions must the nurse take? (Select all that apply.) a. Obtain a stat order for an IV normal saline bolus. b. Administer supplemental oxygen. c. Notify the Rapid Response Team. d. Place the patient in a semi-Fowler's position. e. Call a "code blue."

a, b, c

60. The nurse should instruct a patient who is taking hydrocortisone to report which symptoms to the health care provider for possible does adjustment? (Select all that apply.) a. Rapid weight gain b. Round face c. Fluid retnetion d. Gastrointestinal irritation e. Urinary incontinence

a, b, c

46. Which are physical findings of Cushing's disease? (Select all that apply.) a. "Moon-faced" appearance b. Decreased amount of body hair c. Truncal obesity d. Coarse facial features e. Thin, easily damaged skin f. Extremity muscle wasting

a, c, e, f

27. The nurse finds a patient on the bathroom floor. There is a large amount of blood on the floor and on the patient's hospital gown. Which actions must the nurse take? (Select all that appyl.) a. Elevate the patient's legs. b. Establish large-bore IV access. c. Look for the source of the bleeding. d. Ensure a patient airway. e. Begin a nitroprusside (Nitropress) infusion.

a, b, c, d

12. Which statements about the etiology of hypopituitarism are correct? (Select all that apply.) a. Dysfunction can result from radiation treatment to the head or brain. b. Dysfunction can result from infection or a brain tumor. c. Infarction following systemic shock can result in hypopituitarism. d. Severe malnutrition and body fat depletion can depress pituitary gland function. e. There is always an underlying cause of hypopituitarism.

a, b, c, d Dysfunction can result from radiation treatment to the head or brain. Dysfunction can result from infection or a brain tumor. Infarction following systemic shock can result in hypopituitarism. Severe malnutrition and body fat depletion can depress pituitary gland function.

52. The home health nurse is visiting a frail older adult patient at risk for sepsis because of failure to thrive and immunosuppression. What does the nurse assess this patient for? (Select all that apply.) a. Signs of skin breakdown and presence of redness or swelling b. Cough or any other symptoms of a cold or the flu c. Appearance and odor of urine, and pain or burning during urination d. Patient's and family's understanding of isolation precautions e. Availability and type of facilities for hand-washing

a, b, c, e

Question 25 of 26 In which newly admitted client situations does the nurse initiate a conversation about advance directives? Select all that apply. a. A client with a non-life-threatening illness b. A person who currently has advance directives c. The client with end-stage kidney disease d. The comatose client who was injured in an automobile crash e. The laboring mother expecting her first child

a, b, c, e A client with a non-life-threatening illness, A person who currently has advance directives, The client with end-stage kidney disease, The laboring mother expecting her All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with "healthy" clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with pre-existing advance directives still needs to be questioned; it is possible that the client's wishes have changed since the documents were established. Clients who have potentially life-threatening diseases or conditions should establish advance directives while they are able to do so. The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives.

10. In caring for a patient with hyperpituirarism, which symptoms does the nurse expect the patient to report? a. Joint pain b. Visual disturbances c. Changes in menstruation d. Increase libido e. Headache f. Fatigue

a, b, c, e, f Joint pain, Visual disturbances, Changes in menstruation, Headache, Fatigue

1. Which statements about shock are true? (Select all that apply.) a. Shock is a whole-body response to tissues not receiving enough oxygen. b. Shock is widespread abnormal cellular metabolism. c. Shock only occurs in the acute care setting. d. shock may occur in older adults in response to urinary tract infections. e. Shock is mostly classified as a disease.

a, b, d

11. The terminally ill patient who is near death has loud, wet respirations that are disturbing to the family. Which interventions by the nurse are appropriate at this time? (Select all that apply.) a. Position the patient on her side. b. Place a small towel under her mouth. c. Use oropharyngeal suctioning to remove the secretions. d. Administer an ordered anticholinergic drug to dry up the secretions. e. Teach family members how to use the suctioning device whenever needed.

a, b, d

11. Which complications of DM are considered emergencies? (Select all that apply.) a. Diabetic ketoacidosis (DKA) b. Hypoglycemia c. Diabetic retinopathy d. Hyperglycemic-hyperosmolar state (HHS) e. Diabetic neuropathy

a, b, d

5. Which cultures tend to have a higher incidence of DM? (Select all that apply.) a. Mexican American b. African American c. Caucasian d. American Indian e. Eastern European

a, b, d

67. Which are signs and symptoms of mild hypoglycemia? (Select all that apply.) a. Headache b. Weakness c. Cold, clammy skin d. Irritability e. Pallor f. Tachycardia

a, b, d

21. Which end-of-life interventions must the nurse be prepared to perform for a dying patient and his or her family? (Select all that apply.) a. Allow the family to verbalize fears and concerns about the impending loss of their loved one. b. Listen and acknowledge the legitimacy of the family's pain. c. Minimize the family's loss by using statements such as "Don't be upset." d. Assist the patient and family with reminiscence or storytelling. e. Work to determine the patient's and family's spiritual needs.

a, b, d, e

21. Which statement about tyep 2 DM are accurate? (Select all that apply.) a. It peaks at about the age of 50. b. Most people with type 2 DM are obese. c. It typically has an abrupt onset. d. People with type 2 DM have insulin resistance. e. It can be treated with oral antidiabetic medications and insulin.

a, b, d, e

51. In developing an individualized meal plan for a patient with diabetes, which goals will be focal points of the plan? (Select all that apply.) a. Maintaining blood glucose levels at or as close to the normal range as possible b. Patient food preferences c. Allowing patients to eat as much as they desire d. Patient cultural preferences e. Limiting food choices only when guided by scientific evidence

a, b, d, e

6. A young woman comes to the emergency department (ED) with lightheadedness and "a feeling of impending doom." Pulse is 110 beats/minute; respirations 30/min; blood pressure 140/90 mm Hg. Which factors does the nurse ask about that could contribute to shock? (Select all that apply.) a. Recent accident or trauma b. Prolonged diarrhea or vomiting c. History of depression or anxiety d. Possibility of pregnancy e. Use of over-the-counter medications

a, b, d, e

36. Which medications are used in SIADH to promote water excretion without causing sodium loss? (Select all that apply.) a. Tolvaptan (Samsca) b. Demeclocycline (Declomycin) c. Furosemide (Lasix) d. Conivaptan (Vaprisol) e. Spironolactone (Aldactone)

a, d

20. The nurse identifies signs and symptoms of internal hemorrhage in a postoperative patient. What is included in the care of this patient for hypovolemic shock? (Select all that apply.) a. Elevate the feet with the head flat or elevated 30 degrees. b. Monitor vital signs every 5 minutes until they are stable. c. Administer clotting factors or plasma. d. Provide oxygen therapy. e. Ensure IV access. f. Notify the Rapid Response Team.

a, b, d, e, f

19. Which statement about caring for a patient with dyspnea are true? (Select all that apply.) a. Pharamcologic interventions should begin early in the course of dyspnea. b. Nonpharmacologic, alternative treatments may be used successfully in place of pharmacologic interventions. c. Dyspnea may be caused by the primary diagnosis or its treatments. d. Diagnostic testing must be used to determine the cause of dyspnea before beginning treatment. e. Oropharyngeal suctioning is appropriate for patients with loud, wet respirations nearing death.

a, c

20. Which statements about type 1 DM are accurate? (Select all that apply.) a. It is an autoimmune disorder. b. Most people with type 1 DM are obese. c. Age of onset is typically younger than 30. d. Etiology can be attributed to viral infections. e. It can be treated with oral antidiabetic medications and insulin.

a, c, d

24. Which statements about DI are accurate? (Select all that apply.) a. It is caused by ADH deficiency. b. It is characterized by a decrease in urination. c. Urine output of greater than 4 L/24 hours is the first diagnostic indication. d. The water loss increases plasma osmolarity. e. Nephrogenic DI can be caused by lithium (Eskalith).

a, c, d

32. In SIADH, which laboratory value does the nurse expect to find? (Select all that apply.) a. Increased sodium in urine b. Elevated serum sodium level c. Increased specific gravity (concentrated urine) d. Decreased serum osmolarity e. Decreased urine specific gravity

a, c, d

56. Which interventions are necessary for a patient with acute adrenal insufficiency (Addisonian crisis)? (Select all that apply.) a. IV infusion of normal saline b. IV infusion of 3% saline c. Hourly glucose monitoring d. Insulin administration e. IV potassium therapy

a, c, d

59. The patient has been diagnosed with sepsis. Following the sepsis resuscitation bundle, which interventions should the nurse expect within the first 3 hours? (Select all that apply.) a. Obtain serum lactate level. b. Begin administering vasopressor drugs. c. Draw blood cultures. d. Administer broad-spectrum antibiotics. e. Assist with insertion of a central venous pressure line.

a, c, d

6. Which items are relevant to the concept of hospice? (Select all that apply.) a. Unit of care is the patient and family. b. Preferred location is the hospital setting. c. Interdisciplinary team approach is used. d. Focus is on alleviating pain and suffering. e. Hospice care does not hasten death.

a, c, d, e

59. SMBG levels is most important in which patients? (Select all that apply.) a. Patients taking multiple daily insulin injections b. Patients with mild type 2 diabetes c. Patients with hypoglycemic unawareness d. Patients using a portable infusion device for insulin administration e. Patients with acute illnesses f. Pregnant patients

a, c, d, e, f

50. The nurse is preparing a teaching session for a patient at risk for septic shock. Which topics does the nurse include in this teaching? (Select all that apply.) a. Wash hands frequently using antimicrobial soap. b. Avoid aspirin and aspirin-containing products. c. Avoid large crows or gatherings where people might be ill. d. Do not share utensils; wash toothbrushes in a dishwasher. e. Take temperature once a week. f. Do not change pet litter boxes.

a, c, d, f

14. For which indications would the nurse be prepared to administer a colloid product? (Select all that apply.) a. Hemorrhagic shock b. Dehydration c. Peripheral tissue hypoxia d. Fluid replacement e. Resotre osmotic pressure

a, c, e

18. In which situations does the nurse teach a patient to perform urine ketone testing? (Select all that apply.) a. Acute illness or stress b. When blood glucose levels are above 240 mg/dL c. When symptoms of DKA are present d. To evaluate the effectiveness of DKA treatment e. When a diabetic patient is in a weight-loss program

a, c, e

18. Which statements about pain management in a patient who is dying are true? (Select all that apply.) a. The patient's pain may come from many areas. b. Patients who are dying should discontinue long-acting opioids. c. Alternative therapies have been shown to be useful when integrated into a pain management plan of care. d. When using massage for patients with cancer, deep pressure is the preferred method. e. Aromatherapy, massage, music therapy, and therapeutic touch are a few alternative therapies that have been shown to be useful.

a, c, e

3. The patient has decreased oxygenation and impaired tissue perfusion. Which clinical manifestations are evidence of onset of the non-progressive or compensatory stages of shock? (Select all that apply.) a. Decreased urine output b. Low-grade fever c. Narrowing pulse pressure d. Decreased heart rate e. Increased heart rate

a, c, e

32. The patient with type 2 diabetes is prescribed sitagliptin (Januvia) for glucose regulation. Which key changes does the nurse teach a patient to report to the health care provider immediately? (Select all that apply.) a. Report any signs of jaundice. b. Report any signs of bleeding. c. Report any blue-grey discoloration of the abdomen. d. Report an cough or flu symptoms. e. Report any sudden onset of abdominal pain.

a, c, e

35. In addition to IV fluids, a patient with SIADH is on a fluid restriction as low as 500 to 600 mL/24 hours. Which serum and urine results demonstrate effectiveness of this treatment? (Select all that apply.) a. Decreased urine specific gravity b. Decreased serum sodium c. Increased urine output d. Increased urine specific gravity e. Increased serum sodium f. Decreased urine output

a, c, e

57. The nurse on a medical unit is presenting an in-service program on how to recognize sepsis. Which patients are at risk for distributive septic shock? (Select all that apply.) a. Older adult with urinary tract infection b. Patient with ruptured aortic aneurysm c. Patient with penumonia d. Patient receiving heparin therapy e. Older adult with sacral pressure ulcers

a, c, e

Review Questions - NCLEX® Examination - Chapter 37 Question 7 of 26 Which clients are at immediate risk for hypovolemic shock? Select all that apply. a. Unrestrained client in motor vehicle accident b. Construction worker c. Athlete d. Surgical intensive care client e. 85-year-old with gastrointestinal virus

a, d, e The client who is unrestrained in a motor vehicle accident is prone to multiple trauma and bleeding. Surgical clients are at high risk for hypovolemic shock owing to fluid loss and hemorrhage. Older adult clients are prone to shock; a gastrointestinal virus results in fluid losses. Unless injured or working in excessive heat, the construction worker and the athlete are not at risk for hypovolemic shock; they may be at risk for dehydration.

Review Questions - NCLEX® Examination - Chapter 37 Question 11 of 26 A client is exhibiting signs and symptoms of early shock. What is important for the nurse to do to support the psychosocial integrity of the client? Select all that apply. a. Ask family members to stay with the client. b. Call the health care provider. c. Increase IV and oxygen rates. d. Remain with the client. e. Reassure the client that everything is being done for him or her.

a, d, e Having a familiar person nearby may provide comfort to the client. The nurse should remain with the client who is demonstrating physiologic deterioration. Offering genuine reassurance supports the client who is anxious. The health care provider should be notified, and increasing IV and oxygen rates may be needed, but these actions do not support the client's psychosocial integrity.

16. A patient is recovering from a transphenoidal hypophysectomy. What postoperative nursing interventions apply to this patient? (Select all that apply.) a. Encouraging the patient to perform deep-breathing exercises b. Vigorous coughing and deep-breathing exercises c. Instructing on the use of a soft-bristled toothbrush for brushing the teeth d. Struct monitoring of fluid balance e. Hourly neurologic checks for first 24 hours f. Instructing the patient to alert the nurse regarding postnasal drip

a, d, e, f

6. A patient is prescribed bromocriptine mesylate (Parlodel). Which information does the nurse teach the patient? (Select all that apply.) a. Get up slowly from a lying position. b. Take medication on an empty stomach. c. Take daily for purposes of raising GH levels to reduce symptom of acromegaly. d. Begin therapy with a maintenance level dose. e. Report watery nasal discharge to the health care provider immediately.

a, e Get up slowly from a lying position. Report watery nasal discharge to the health care provider immediately.

13. Which factors differentiate DKA from HHS? (Select all that apply.) a. Level of hyperglycemia b. Amount of ketones produced c. Serum bicarbonate levels d. Amount of volume depletion e. Dosage of insulin needed

a,b

1. Which statements about the health of older adults in the United States are true? (Select all that apply.) a. The fastest-growing group is between 85-99 years of age. b. Only 5% of older adults are in nursing homes. c. Older adults are at risk for poor nutrition d. Older adults 85-95 years old are often wrongly referred to as the "frail elderly." e. Men live longer than women in the old-old subgroup.

a,b,c,d

47. Which infection control measures must the nurse teach a patient who will be performing SMBG? (Select all that apply.) a. Always wash hands before monitoring glucose. b. Regular cleaning of the meter is critical. c. Do not reuse lancets. d. Do not share blood glucose monitoring equipment. e. Sterilize blood glucose monitor before each use.

a,b,c,d

10. Which factors must the nurse acknowledge and include in discharge education for the older adult about medication administration? (Select all that apply.) a. Suggest a simple type of reminder to take daily medications. b. Ensure that medication labels have large print to assist patients with identification. c. Request easy-open caps for medication bottles and ensure that they remain out of reach of visiting children. d. Instruct patients that use of herbal supplements without consulting the health care provider is acceptable. e. Provide a complete list of the patient's regularly taken over-the-counter medicaitions to health care providers.

a,b,c,e

20. What are signs indicating that the older adult is experiencing dementia or delirium? (Select all that apply.) a. Temporary, acute confusion b. Progressive loss of cognitive function c. Agitation and combative behavior d. Complaints of weakness or dizziness e. sudden onset of apathy and withdrawn behavior

a,b,c,e

2. The nurse is caring for an older adult patient. What are the best interventions to help reduce relocation stress in this patient? (Select all that apply.) a. Explain all procedures to the patient before they occur. b. Reorient the patient frequently to location. c. Allow the patient adequate time for rest, and encourage family and friends to keep their visits to a minium. d. Provide ample opportunity and time for the patient to participate in decision making. e. Arrange for familiar keepsakes to be at the patient's bedside.

a,b,d,e

Iggy Study Guide Ch.59 29. The nurse is caring for a patient with pancreatic cancer who had a Whipple procedure. Which interventions and assessments does the nurse implement? (Select all that apply.) a. Place the patient in semi-Fowler's position. b. Place the NG tube on intermittent suction. c. Monitor NG drainage, which should be bile-tinged and contain blood. d. Keep the patient NPO. e. Check blood glucose often.

a,b,d,e

49. Intensive therapy with good glucose control results in delays in which diabetic complications? (Select all that apply.) a. Macrovascular disease b. Cardiovascular disease c. Stroke d. Retinopathy e. Nephropathy f. Neuropathy

a,b,d,e,f

13. Which symptoms of depression in older adults should be carefully evaluated by the health care provider? (Select all that apply.) a. Early morning insomnia b. Reluctance to participate in social activities c. Reminiscing about the past d. Normalization of appetie and intake e. Excessive daytime sleeping.

a,b,e

15. Which statements regarding elder abuse are true? (Select all that apply.) a. The abuser is often a close family member or caregiver. b. Only physically dependent older adults are vulnerable to elder abuse. c. Elder neglect is categorized as a type of elder abuse. d. Elder abuse includes misuse of patients' money or property. e. There is a need for mandatory reporting laws for suspected elder abuse.

a,c,d

Iggy Study Guide Ch.59 13. Which statements are true regarding laparoscopic cholecystectomy? (Select all that apply.) a. Laparoscopic cholecystectomy is considered the "gold standard" and is performed far more often than the traditional open approach. b. Patients with chronic lung disease or heart failure who are unable to tolerate the oxygen used in the laparoscopic procedure are examples of patients who have the open surgical approach (abdominal laparotomy). c. Removing the gallbladder with the laparoscopic techinique reduces the risk of wound complications. d. Patients who have their gallbladders removed by the laparoscopic technique should be taught the importance of early ambulation to promote absorption of carbon dioxide. f. Use of laparoscopic cholecystectomy puts the patient at increased risk for bile duct injuries.

a,c,d

Iggy Study Guide Ch.59 34. Which are potential cardiovascular complications for a patient after surgery for a Whipple procedure? (Select all that apply.) a. Thrombophlebitis b. Pulmonary embolism c. Myocardial infarction d. Heart failure e. Renal failure

a,c,d

7. The nurse is caring for the confused older patient who is at risk for falls. Which interventions should the nurse implement to ensure patient safety? (Select all that apply.) a. Remind the patient to use ambulatory devices as neede. b. Instruct the patient to limit activity as much as possible. c. Provide appropriate lighting in the patient's environment. d. Make sure the patient's eyeglasses are functional, and routine eye examinations have been performed. e. Implement facility-specific fal protocoals.

a,c,d,e

78. The nurse is preparing to teach a diabetic patient how to select appropriate shoes. Which points must be included in the teaching plan? (Select all that apply.) a. "It is best to have the shoes fitted by an experienced shoe fitter such as a podiatrist." b. "The shoes should be 1 to 1.5 inches longer than your longest toe." c. "The heels of the shoes should be less than 2 inches high." d. "Avoid tight-fitting shoes, which can cause tissue damage to your feet." e. "You should get at least two pairs of shoes so you can change them at midday and in the evening."

a,c,d,e

3. Which statements would be included in an educational program on wellness behaviors for the older adult? (Select all that apply.) a. Allow at least 10-15 minutes of sun exposure 2-3 times weekly. b. Take one aspirin twice a day. c. Obtain a yearly influenza vaccination. d. Create a hazard-free environment to prevent falls. e. Increased dietary needs include calcium and vitamins A,D,and C f. Reduce dietary intake of complex carbohydrates and fiber. g. Drink 6-8 glasses of water per day to prevent dehydration.

a,c,d,e,g

Iggy Study Guide Ch.59 5. Which are common manifestations of acute cholecystitis? (Select all that apply.) a. Anorexia b. Ascites c. Eructation d. Steatorrhea e. Jaundice f. Rebound tenderness

a,c,e,f

8. The patient required physical restraints. Which interventions must the nurse perform for this patient? (Select all that apply.) a. Check the aptient every 30-60 minutes. b. Release the restraints at least every 4 hours. c. Turn on the television to provide distraction. d. Place the patient in an area for careful observation. e. Decrease communication with the patient.

a,d

19. Which factors place the older adult at increased risk for a fall? (Select all that apply.) a. Age>90 b. Urinary continence c. Corrected visual impairment d. Postural instability e. Impaired communication

a,d,e

5. What are the direct benefits of exercise? (Select all that apply.) a. Decreased depression symptoms b. Reduces muscle strength c. Improves sleep apnea d. Increases mobility e. Decreases risk of heart disease f. Reduces or maintains body weight

a,d,e,f

12. Which interventions are effective in helping to reorient the older adult who is suffering from delirium? (Select all that apply.) a. Talk to the patient using a calm voice. b Restrict visitors during periods of agitation. c. Remove personal items and store them safely. d. Apply wrist restraints to keep the patient from endangering him-or herself. e. Provide calming music

a,e

p. 109, Safety The emergency department manager has created a task force to decrease the rate of adverse incidents in patients who have increased safety needs during their stay in the department. At their meeting, each person discussed a specific safety need and actions that can be taken to reduce that risk. 3. What actions can be delegated to unlicensed personnel in the following areas: medication administration, skin protection, and fall risk?

a. Medication administration: none b. Skin protection: Institute turning schedule, keep linens dry and wrinkle free, keep incontinent patients clean and dry, offer trips to the bathroom frequently for those who can walk, and ensure that the patient is not lying on supplies or other items. c. Fall risk: Sit with the patient, reorient the patient, ensure that the call light is within reach, ensure that side rails are up, and ask about personal needs (e.g., bathroom, water as allowed).

15. What type of insulin is used in the emergency treatment of DKA and hyperglycemic-hyperosmolar nonketotic syndrome (HHNS)? a. NPH b. Lente c. Regular d. Protamine zinc

34. A patient has a systemic infection with a fever, increased respiratory rate, and change in mental status. Which laboratory values does the nurse seek out that are considered "hallmark" of sepsis? a. Increased white blood count and increased glucose level b. Increased serum lactate level and rising band neutrophils c. Increased oxygen saturation and decreased clotting times d. Decreased white blood count with increased hematocrit

35. A diabetic patient is on a mixed-dose insulin protocol of 8 units regular insulin and 12 units NPH insulin at 7 AM. At 10:30 AM, the patient reports feeling uneasy, shaky, and has a headache. Which is the probable explanation for this? a. The NPH insulin's action is peaking, and there is an insufficient blood glucose level. b. The regular insulin's action is peaking, and there is an insufficient blood glucose level. c. The patient consumed too many calories at breakfast and now has an elevated blood glucose level. d. The symptoms are unrelated to the insulin administered in the early morning or food taken in at lunchtime.

37. Which statement about pheochromocytoma is correct? a. It is most often malignant. b. It is a catecholamine-producing tumor. c. It is found only in the adrenal medulla. d. It is manifested by hypotension.

38. A patient in the emergency department is diagnosed with possible pheochromcytoma. What is the priority nursing intervention for this patient? a. Monitor the patient's intake and output and urine specific gravity. b. Monitor blood pressure for severe hypertension. c. Monitor blood pressure for severe hypotension. d. Administer medication to increase cardiac output.

4. A patient with diabetes presents to the emergency department (ED) with a blood sugar of 640 mg/dL and reports being constantly thirsty and having to urinate "all of the time." How does the nurse document this subjective finding? a. Polydipsia and polyphagia b. Polydipsia and polyuria c. Polycoria and polyuria d. Polyphagia and Polyesthesia

40. Which intervention applies to a patient with pheochromocytoma? a. Assist to sit in a chair for blood pressure monitoring. b. Instruct not to smoke, drink coffee, or change positions suddenly. c. Encourage to maintain an active exercise schedule including activity such as running. d. Encourage one glass of red wine nightly to promote rest.

41. Which intervention is contraindicated for a patient with pheochromocytoma? a. Monitoring blood pressure b. Palpating the abdomen c. Collecting 24-hour urine specimens d. Instructing the patient to limit activity

43. The nurse is caring for a patient with septic shock. Which therapy specific to the management of septic shock for this patient does the nurse anticipate will be used? a. Inotropics b. Antibiotics c. colloids d. Antidysrhythmics

44. Which diabetic complication is associated with neuropathy? a. End-stage kidney disease b. Muscle weakness c. Permanent blindness d. Eye hemorrhage

50. Which drug decreases cortisol production? a. Mitotane (Lysodren) b. Aminoglutethimide (Cytadren) c. Cyproheptadine (Periactin) d. Hydrocortisone (Cortef)

51. A patient is scheduled for bilateral adrenalectomy. Before surgery, steroids are to be given. Which is the reasoning behind the administration of this drug? a. To promote glycogen storage by the liver for body energy reserves b. To compensate for sudden lack of adrenal hormones following surgery c. To increase the body's inflammatory response to promote scar formation d. To enhance urinary excretion of salt and water following surgery

53. A postoperative hospitalized patient has a decrease in MAP of greater than 20 mm Hg from baseline value; elevated, thready pulse; decreased blood pressure; shallow respirations of 26/min; pale skin; moderate acidosis; and moderate hyperkalemia. The nurse recognizes that this patient is in what phase of shock? a. Compensatory/nonprogressive b. Progressive c. Refractory d. Multiple organ dysfunction

53. Which statement about a patient with hyperaldosteronism after a successful unilateral adrenalectomy is correct? a. The low-sodium diet must be continued postoperatively. b. Glucocorticoid replacement therapy is temporary. c. Spironolactone (Aldactone) must be taken for life. d. Additional measures are needed to control hypertension.

53. Which statement dietary concepts for a patient with diabetes is true? a. Alcoholic beverage consumption is unrestricted. b. Carbohydrate counting is emphasized when adjusting dietary intake of nutrients. c. Sweeteners should be avoided because of the side effects. d. Both soluble and insoluble fiber foods should be limited.

55. Along with exercise, what is the recommended calorie reduction for a patient with diabetes who must lose weight? a. 100-200 calories/day b. 250-500 calories/day c. 501-600 calories/day d. 601-750 calories/day

55. The clinical manifestations in the first phase of sepsis-induced distributive shock results from the body's reaction to which factor? a. Leukocytes b. Infectious microorganisms c. Hemorrhage d. Hypovolemia

57. A patient in the emergency department who reports lethargy, muscle weakness, nausea, vomiting, and weight loss over the past weeks is diagnosed with Addisonian crisis (acute adrenal insufficiency). Which drug(s) does the nurse expect to administer to this patient? a. Beta blocker to control the hypertension and dysrhythmias b. Solu-Cortef IV along with IM injections of hydrocortisone c. IV fluids of D5NS with KCl added for dehydration d. Spironolactone (Aldactone) to promote diuresis

61. A patient with type 1 Dm is planning to travel by air and asks the nurse about preparations for the trip. What does the nurse tell the patient to do? a. Pack insulin and syringes in a labeled, crushproof kit in the checked luggage. b. Carry all necessary diabetes supplies in a clearly identified pack aboard the plane. c. Ask the flight attendant to put the insulin in the gallery refrigerator once on the plane. d. Take only minimal supplies and get the prescription filled at his or her destination.

65. A patient with type 2 DM often has which laboratory value? a. Elevated thyroid studies b. Elevated triglycerides c. Ketones in the urine d. Low hemoglobin

73. A patient with DM has signs and symptoms of hypoglycemia. The patient is alert and oriented with a blood glucose of 56 mg/dL. What does the nurse do next? a. Give a glass of orange juice with two packets of sugar and continue to monitor the patient. b. Give 8 oz of skim milk and then a carbohydrate and protein snack. c. Give a complex carbohydrate and continue to monitor the patient. d. Administer D50 IV push and give the patient something to eat.

Iggy Study Guide Ch.59 11. The nurse is caring for an older adult patient with acute biliary pain. Which drug order does the nurse question? a. Ketorolac (Toradol, Acular) b. Meperidine (Demerol) c. Morphine d. Hydromorphone (Dilaudid)

Iggy Study Guide Ch.59 17. The patient with acute cholecystitis had a pacemaker. Which diagnostic test is contraindicated? a. ERCP b. Magnetic resonance cholangiopancreatography (MRCP) c. Ultrasonography of the right upper quadrant d. Hepatobilliary (HIDA) scan

Iggy Study Guide Ch.59 8. A patient is scheduled for tests to verify the medical diagnosis of cholecystitis. For which diagnostic test does the nurse provide patient teaching? a. Extracorporeal shock was lithotripsy b. Ultrasonography of the right upper quadrant c. Endoscopic retrograde cholangiopancreatography (CRCP) d. Serum level of aspartate aminotransferase (AST)

Question 21 of 26 A client admitted with a non-life-threatening illness says, "I was asked to fill out an advance directive when I was admitted, but I was too stressed. What was it all about?" How does the nurse respond? a. "Advance directives are only for those individuals who are severely ill." b. "Advance directives allow a client to convey his or her wishes about health care ahead of time." c. "Most Americans have an advance directive in place; you will need to see a lawyer." d. "You should have completed the paperwork before you were admitted."

b "Advance directives allow a client to convey his or her wishes about health care ahead of time." Stating that advanced directives allow a client to convey his or her wishes about health care ahead of time is true and best addresses the client's comments. Advance directives should be in place before the client becomes severely ill. Most Americans do not have advance directives in place. Legal assistance is not necessary to complete them. Although completing paperwork pertaining to advance directives before admission would be ideal, any time is a good time to do this.

Question 6 of 10 As a direct result of overcrowding in emergency department (ED) environments, for whom must the emergency department nurse expect to provide care? a. A variety of age groups and cultures b. "Boarding" or holding inpatient clients c. Clients with a broad spectrum of issues, illnesses, and injuries d. Uninsured and underinsured clients

b "Boarding" or holding inpatient clients ED overcrowding has become a widespread problem, with frequent boarding or holding of admitted clients in the ED because of lack of beds in the hospital. The ED nurse must be adept at providing safe and competent care to clients who are awaiting bed placement. The focus then becomes one of ongoing care (scheduled medications, testing) instead of one-time orders. Although a variety of age groups and cultures; clients with a broad spectrum of illness, issues, and injuries; and uninsured/underinsured clients are seen in the ED, this is not a result of overcrowding.

Question 26 of 26 The daughter of a dying client says, "I don't want my father to be uncomfortable." How does the nurse respond? a. "Do you want to talk to the bereavement nurse?" b. "Your father will be closely monitored and cared for." c. "Your father will be kept sedated." d. "We will send him to hospice when the time comes."

b "Your father will be closely monitored and cared for." Telling the daughter that her father will be closely monitored and cared for provides support and comfort. The daughter's comment does not require the expertise of a bereavement nurse. Also, asking if the daughter wants to talk to a bereavement nurse is a "yes-or-no" question and a nontherapeutic response; it shuts off the dialog. The dying client is not typically kept sedated; clients are kept comfortable with as little or as much pain medication as needed. A goal is to keep him or her alert and able to communicate. Telling the daughter that her father will be sent to hospice when the time comes does not address the daughter's concern about her father's comfort; it closes the dialog.

11. A client has just been diagnosed with diabetes. Which factor is most important for the nurse to assess in the client before providing instruction about the disease and its management? a. Current lifestyle b. Educational and literacy level c. Sexual orientation d. Current energy level

b A large amount of information must be synthesized; typically written instructions are given. The client's educational and literacy level is essential information. Although lifestyle should be taken into account, it is not the priority. Sexual orientation will have no bearing on the ability of the client to provide self-care. Although energy level will influence the ability to exercise, it is not essential.

Question 22 of 26 The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the nursing assistant to visit? a. Advanced cirrhosis of the liver; called the hospice agency reporting nausea b. Aggressive brain tumor; needs daily assistance with ambulation and bathing c. Inoperable lung cancer; considering whether to have radiation and chemotherapy d. Prostate cancer and bone metastases; has new-onset leg weakness and tingling

b Aggressive brain tumor; needs daily assistance with ambulation and bathing Assisting clients with activities of daily living is a common role for nursing assistants working in home health or hospice agencies. Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions, which are within the RN scope of practice.

Question 12 of 26 A dying client is having difficulty swallowing oral medications. Which intervention does the nurse implement for this client? a. Asks the pharmacy to substitute intramuscular (IM) equivalents for the medications b. Asks the provider if the medications can be discontinued or substituted c. Crushes the pills, opens the sustained-release capsules, and mixes them with a spoonful of applesauce d. Does not give the medications and documents: "Unable to swallow"

b Asks the provider if the medications can be discontinued or substituted Since the client is in the dying process, he or she may no longer require some of the medications prescribed, and other routes may be available for medications that will promote comfort. The IM route is almost never used for clients at the end of life because this method is invasive and painful, and can cause infection. Although some pills may be crushed, sustained-release capsules should not be taken apart and their contents administered directly. The client may still need the medications prescribed for comfort; withholding them could cause discomfort throughout the dying process.

Review Questions - NCLEX® Examination - Chapter 37 Question 17 of 26 A client with septic shock has been started on dopamine (Intropin) at 12 mcg/kg/min. Which response indicates a positive outcome? a. Hourly urine output 10 to 12 mL/hr b. Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg c. Blood glucose 245 mg/dL d. Serum creatinine 3.6 mg/dL

b Blood pressure 90/60 mm Hg and mean arterial pressure 70 mm Hg Dopamine improves blood flow by increasing peripheral resistance, which increases blood pressure—a positive response in this case. Urine output less than 30 mL/hr or 0.5 mL/kg/hr and elevations in serum creatinine indicate poor tissue perfusion to the kidney and are a negative consequence of shock, not a positive response. Although a blood glucose of 245 mg/dL is an abnormal finding, dopamine increases blood pressure and myocardial contractility, not glucose levels.

Review Questions - NCLEX® Examination - Chapter 37 Question 2 of 26 Which problem in the clients below best demonstrates the highest risk for hypovolemic shock? a. Client receiving a blood transfusion b. Client with severe ascites c. Client with myocardial infarction d. Client with syndrome of inappropriate antidiuretic hormone (SIADH) secretion

b Client with severe ascites Fluid shifts from vascular to intra-abdominal may cause decreased circulating blood volume and poor tissue perfusion. Volume depletion is only one reason why a person may require a blood transfusion; anemia is another. The client receiving a blood transfusion does not have as high a risk as the client with severe ascites. Myocardial infarction results in tissue necrosis in the heart muscle; no blood or fluid losses occur. Owing to excess antidiuretic hormone secretion, the client with SIADH will retain fluid and therefore is not at risk for hypovolemic shock.

Question 15 of 26 The nurse recognizes signs and symptoms of depression in an 80-year-old client who is dying from metastatic breast cancer. What does the nurse do initially for this client? a. Assesses these behaviors as normal steps or stages in the grief process for the client b. Collaborates with the end-of-life (EOL) care team to manage these feelings in the client c. Documents these findings and continues to monitor the client d. Reduces the quantity of depression-causing opioids that are being administered to the client

b Collaborates with the end-of-life (EOL) care team to manage these feelings in the client Behaviors should be assessed and treated with the collaboration of the EOL care team. The nurse may be instrumental in performing a "depression" screening. Feelings of depression—hopelessness, helplessness, unhappiness—are not part of the aging process or the process of dying; they should be aggressively treated. These feelings should not only be documented and monitored, but also should be acknowledged as not a normal part of the dying process and should be treated with psychotherapy or medications or both. Inadequate analgesic pain control is one of the most noted and critical problems, especially in older adults. This scenario would not be a reason for opioid administration to be reduced; such an action is harmful to the client.

Question 8 of 10 The provider is planning to discharge a client home. The nurse suspects domestic violence as the cause of injury, although the client denies this. What is the best course of action for the nurse to take? a. Call the police. b. Consult with Social Services. c. Discharge the client as instructed. d. Instruct the client to go to a safe place.

b Consult with Social Services. If discharge home is not deemed safe, the client may be admitted to the hospital until resources can be organized to provide a safe environment. Social workers or case managers are consulted to investigate resource needs and plan accordingly. Calling the police is not an appropriate response. Letting the client go home could place the client in danger. The client may not have a safe place to go.

Question 1 of 10 A client from a local care facility has sustained a cardiac arrest in the emergency department (ED), and resuscitation was unsuccessful. The client's family wishes to view the body. What steps should the ED nurse take? a. Remove all lines and indwelling tubes. b. Cover the client with a sheet, leaving the face exposed. c. Call a chaplain or social worker to accompany the family. d. Tell the family that the client "is in a better place now." e. Dim the lights in the client's room.

b Cover the client with a sheet, leaving the face exposed. Not all clients presenting to the ED survive to discharge. The client's family has the right to view the body prior to removal to the morgue or funeral home. Dimming the lights in the room and covering the body with a sheet or blanket should be done prior to the family viewing. Leaving the head exposed allows the family to see the client and to comprehend that the death has occurred. IV lines and indwelling tubes may need to be left in place unless their removal has been authorized. The family should be escorted to the room by hospital personnel; however, this is not always exclusively done by a chaplain or social worker. The nurse must exhibit compassion and empathy; however, using terms such as "died" and "dead" create less confusion than "in a better place."

Review Questions - NCLEX® Examination - Chapter 37 Question 12 of 26 Which laboratory result is seen in late sepsis? a. Decreased serum lactate b. Decreased segmented neutrophil count c. Increased numbers of monocytes d. Increased platelet count

b Decreased segmented neutrophil count A decreased segmented neutrophil count is indicative of late sepsis. Serum lactate is increased in late sepsis. Monocytosis is usually seen in diseases such as tuberculosis and Rocky Mountain spotted fever. An increased platelet count does not indicate sepsis; late in sepsis, platelets may decrease due to consumptive coagulopathy.

4. The nurse is teaching a client about the manifestations and emergency treatment of hypoglycemia. In assessing the client's knowledge, the nurse asks the client what he or she should do if feeling hungry and shaky. Which response by the client indicates a correct understanding of hypoglycemia management? a. "I should drink a glass of water." b. "I should eat three graham crackers." c. "I should give myself 1 mg of glucagon." d. "I should sit down and rest."

b Eating three graham crackers is a correct management strategy for mild hypoglycemia. Water or resting does not remedy hypoglycemia. Glucagon should be administered only in cases of severe hypoglycemia.

Review Questions - NCLEX® Examination - Chapter 37 Question 4 of 26 The nurse plans to administer an antibiotic to a client newly admitted with septic shock. What action does the nurse take first? a. Administer the antibiotic immediately. b. Ensure that blood cultures were drawn. c. Obtain signature for informed consent. d. Take the client's vital signs.

b Ensure that blood cultures were drawn. Cultures must be taken to identify the organism for more targeted antibiotic treatment before antibiotics are administered. Antibiotics are not administered until after all cultures are taken. A signed consent is not needed for medication administration. Monitoring the client's vital signs is important, but the antibiotic must be administered within 1 to 3 hours; timing is essential.

24. The nurse is providing discharge teaching to a client with newly diagnosed diabetes. Which statement by the client indicates a correct understanding about the need to wear a MedicAlert bracelet? a. "If I become hyperglycemic, it is a medical emergency." b. "If I become hypoglycemic, I could become unconscious." c. "Medical personnel may need confirmation of my insurance." d. "I may need to be admitted to the hospital suddenly."

b Hypoglycemia is the most common cause of medical emergency in clients with diabetes. A MedicAlert bracelet is helpful if the client becomes hypoglycemic and is unable to provide self-care. Hyperglycemia is not a medical emergency unless it is acidosis; people with diabetes tolerate mild hyperglycemia routinely. Insurance information and information needed for hospital admission do not appear on a MedicAlert bracelet.

Review Questions - NCLEX® Examination - Chapter 37 Question 19 of 26 How does the nurse caring for a client with septic shock recognize that severe tissue hypoxia is present? a. PaCO2 58 mm Hg b. Lactate 9.0 mmol/L c. Partial thromboplastin time 64 seconds d. Potassium 2.8 mEq/L

b Lactate 9.0 mmol/L Poor tissue oxygenation at the cellular level causes anaerobic metabolism, with the by-product of lactic acid. Elevated partial pressure of carbon dioxide occurs with hypoventilation, which may be related to respiratory muscle fatigue, secretions, and causes other than hypoxia. Coagulation times reflect the ability of the blood to clot, not oxygenation at the cellular level. Elevation in potassium appears in septic shock due to acidosis; this value is decreased and is not consistent with septic shock.

Review Questions - NCLEX® Examination - Chapter 37 Question 6 of 26 Which clinical symptoms in a postoperative client indicate early sepsis with an excellent recovery rate if treated? a. Localized erythema and edema b. Low-grade fever and mild hypotension c. Low oxygen saturation rate and decreased cognition d. Reduced urinary output and increased respiratory rate

b Low-grade fever and mild hypotension Low-grade fever and mild hypotension indicate very early sepsis, but with treatment, the probability of recovery is high. Localized erythema and edema indicate local infection. A low oxygen saturation rate and decreased cognition indicate active (not early) sepsis. Reduced urinary output and increased respiratory rate indicate severe sepsis.

Review Questions - NCLEX® Examination - Chapter 37 Question 26 of 26 How does the nurse recognize that a positive outcome has occurred when administering plasma protein fraction (Plasmanate)? a. Urine output 20 to 30 mL/hr for the last 4 hours b. Mean arterial pressure (MAP) 70 mm Hg c. Albumin 3.5 g/dL d. Hemoglobin 7.6 g/dL

b Mean arterial pressure (MAP) 70 mm Hg Plasmanate expands the blood volume and helps maintain MAP greater than 65 mm Hg, which is a desired outcome in shock. Urine output should be 0.5 mL/kg/hr, or greater than 30 mL/hr. Albumin levels reflect nutritional status, which may be poor in shock states due to an increased need for calories. Plasmanate expands blood volume by exerting increasing colloid osmotic pressure in the bloodstream, pulling fluid into the vascular space; this does not improve an abnormal hemoglobin.

Review Questions - NCLEX® Examination - Chapter 37 Question 9 of 26 A postoperative client is admitted to the intensive care unit with hypovolemic shock. Which nursing action does the nurse delegate to an experienced nursing assistant? a. Obtain vital signs every 15 minutes. b. Measure hourly urine output. c. Check oxygen saturation. d. Assess level of alertness.

b Measure hourly urine output. Monitoring hourly urine output is included in nursing assistant education and does not require special clinical judgment; the nurse evaluates the results. Obtaining vital signs, monitoring oxygen saturation, and assessing mental status in critically ill clients requires the clinical judgment of the critical care nurse because immediate intervention may be needed.

Question 9 of 26 A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order does the nurse implement first? a. Albuterol (Proventil) 0.5% solution per nebulizer b. Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed c. Oxygen 2 to 6 L/min per nasal cannula d. Prednisone (Deltasone) elixir 10 mg orally

b Morphine sulfate (Roxanol) 5 to 10 mg sublingually as needed Morphine sulfate is the standard treatment for the dyspneic client who is near death. Albuterol (Proventil), oxygen, and steroids may be useful, but should be used as adjuncts to therapy with morphine.

7. A client with type 1 diabetes mellitus received regular insulin at 7:00 a.m. The client should be monitored for hypoglycemia at which time? a. 7:30 a.m. b. 11:00 a.m. c. 2:00 p.m. d. 7:30 p.m.

b Onset of regular insulin is ½ to 1 hour; peak is 2 to 4 hours. Therefore, 11:00 a.m. is the anticipated peak time for regular insulin received at 7:00 a.m. For regular insulin received at 7:00 a.m., 7:30 a.m., 2:00 p.m., and 7:30 p.m. are not the anticipated peak times.

Question 10 of 26 A dying client cannot swallow and is accumulating audible mucus in the upper airway (death rattles). The nursing assistant reports that these noises are upsetting to family members. What does the nurse tell the assistant to do? a. Assist the family in leaving the room so that they can compose themselves. b. Place the client in a side-lying position so secretions can drain. c. Position the client in a high-Fowler's position to minimize secretions. d. Use a Yankauer suction tip to remove secretions from the client's upper airway.

b Place the client in a side-lying position so secretions can drain. Placing the client in a side-lying position to facilitate draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease. Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler's position is ineffective in helping the client who has lost the ability to swallow; the danger of choking and aspiration would increase. Not only is oropharyngeal suctioning outside the scope of practice of the nursing assistant, it is also not recommended for removal of secretions, because it is not effective and may even agitate the dying client.

NCLEX® Examination Challenges IGGY Ch.64 p. 1328, Health Promotion and Maintenance While assessing the client who has had diabetes for 15 years, the nurse finds that he has decreased sensory perception in both feet. What is the nurse's best first action? A. Document the finding as the only action. B. Examine the feet for manifestations of injury. C. Test the sensory perception of the client's hands. D. Tell the client that he now has peripheral neuropathy.

b Rationale: When reduced peripheral sensory perception is present, the likelihood of injury is high. Any open area or other problem on the foot of a person with diabetes is at great risk for infection and must be managed carefully and quickly. Checking for sensory perception on the hands and other areas is important but can come after a thorough foot examination.

14. A client newly diagnosed with diabetes is not ready or willing to learn diabetes control during the hospital stay. Which information is the priority for the nurse to teach the client and the client's family? a. Causes and treatment of hyperglycemia b. Causes and treatment of hypoglycemia c. Dietary control d. Insulin administration

b The causes and treatment of hypoglycemia must be understood by the client and family to manage the client's diabetes effectively. The causes and treatment of hyperglycemia is a topic for secondary teaching and is not the priority for the client with diabetes. Dietary control and insulin administration are important, but are not the priority in this situation.

16. The nurse has just taken change-of-shift report on a group of clients on the medical-surgical unit. Which client does the nurse assess first? a. Client taking repaglinide (Prandin) who has nausea and back pain b. Client taking glyburide (Diabeta) who is dizzy and sweaty c. Client taking metformin (Glucophage) who has abdominal cramps d. Client taking pioglitazone (Actos) who has bilateral ankle swelling

b The client taking glyburide (Diabeta) who is dizzy and sweaty has symptoms consistent with hypoglycemia and should be assessed first because this client displays the most serious adverse effect of antidiabetic medications. Although the client taking repaglinide who has nausea and back pain requires assessment, the client taking glyburide takes priority. Metformin may cause abdominal cramping and diarrhea, but the client taking it does not require immediate assessment. Ankle swelling is an expected side effect of pioglitazone.

8. The nurse is performing an assessment of an adult patient with new-onset acromegaly. What does the nurse expect to find? a. Extremely long arms and legs b. Thickened lips c. Changes in menses with infertility d. Rough, extremely dry skin

b Thickened lips

9. The nurse is teaching a client with diabetes about proper foot care. Which statement by the client indicates that teaching was effective? a. "I should go barefoot in my house so that my feet are exposed to air." b. "I must inspect my shoes for foreign objects before putting them on." c. "I will soak my feet in warm water to soften calluses before trying to remove them." d. "I must wear canvas shoes as much as possible to decrease pressure on my feet."

b To avoid injury or trauma to the feet, shoes should be inspected for foreign objects before they are put on. Diabetic clients should not go barefoot because foot injuries can occur. To avoid injury or trauma, a callus should be removed by a podiatrist, not by the client. The diabetic client must wear firm support shoes to prevent injury.

43. The diabetic patient experiences early morning hyperglycemia (Somogyi effect) as a result of the counterregulatory response to hypoglycemia. What treatment does the nurse expect for this condition? (Select all that apply.) a. Administer a 10 PM dose of intermediate-acting insulin. b. Provide an evening snack to ensure adequate dietary intake. c. Evaluate insulin dosage and exercise program. d. Add an oral antidiabetic drug to patient's regimen. e. Increase blood glucose checks to every 2 hours around the clock.

b, c

1. Which are direct causes of death? (Select all that apply.) a. GI bleeding b. Heart failure c. Respiratory failure d. Shock e. Kidney failure

b, c, d

12. In determining if a patient is hypoglycemic, the nurse looks for which characteristics in addition to checking the patient's blood glucose? (Select all that apply.) a. Nausea b. Hunger c. Irritability d. Palpitations e. Profuse perspiration f. Rapid, deep respirations

b, c, d, e

13. Which interventions after a patient's death are appropriate to perform? (Select all that apply.) a. Remove the body to the morgue or funeral home immediately after death. b. Follow agency policies to remove all tubes and lines from the body. c. Make sure that the physician has completed and signed the death certificate. d. Provide privacy for the family and significant others with the deceased. e. Allow family and/or significant other to perform religious and cultural customs.

b, c, d, e

24. The nurse is providing discharge teaching to a patient about self-monitoring of blood glucose (SMBG). What information does the nurse include? (Select all that apply.) a. Only perform SMBG before breakfast. b. Wash hands before using the meter. c. Do a retest if the results seem unusual. d. It is okay to reuse lancets in the home setting. e. Do not share the meter.

b, c, e

25. What does the nurse instruct patients with permanent DI to do? (Select all that apply.) a. Continue vasopressin therapy until symptoms disappear. b. Monitor for recurrent of polydipsia and polyuria. c. Monitor and record weight daily. d. Check urine specific gravity three times a week. e. Wear a medical alert bracelet.

b, c, e

47. Which laboratory findings does the nurse expect to find with Cushing's syndrome? (Select all that apply.) a. Decreased serum sodium b. Increased serum glucose c. Increased serum sodium d. Increased serum potassium e. Decreased serum calcium

b, c, e

68. The older adult with DM asks the nurse for advice about beginning an exercise program. What is the nurse's best response? (Select all that apply.) a. Begin with high-intensity activities. b. Start low-intensity activities in short sessions. c. Be sure to include warm-up and cool-down periods. d. Start with periods of 20 minutes or less. e. Changes in activity should be gradual.

b, c, e

7. Which characteristics apply to the concept of palliative care? (Select all that apply.) a. Patient must have less than a year to live. b. Care time is not limited to specific periods of time. c. Care focus is curative or may prolong life. d. Care is provided when curative treatments have been stopped. e. Patient can be in any stage of serious illness.

b, c, e

1. Which descriptors are typical of type 2 diabetes mellitus (DM)? (Select all that apply.) a. Autoimmune process causes beta cell destruction. b. Cells have decreased ability to respond to insulin. c. Diagnosis is based on results of 100-g glucose tolerance test. d. Most patients diagnosed are obese adults. e. Usually has abrupt onset of thirst and weight loss.

b, d

7. Which are specific causes or risk factors for cardiogenic shock? (Select all that apply.) a. Anesthesia b. Myocardial infarction c. Cardiac tamponade d. Ventricular dysrhythmias e. Constrictive pericarditis

b, d

77. Which are characteristics of regular insulin? (Select all that apply.) a. This insulin does not have a peak time. b. When mixing types of insulin, this insulin is always drawn up first. c. This insulin is given once daily for basal insulin coverage. d. This insulin should be given 30 minutes before meals. e. This insulin should not be diluted or mixed with any other insulin.

b, d

41. Which insulins are considered to have a rapid onset of action? (Select all that apply.) a. Novolin 70/30 b. Glulisine c. Humulin N d. Aspart e. Lispro

b, d, e

18. A patient is brouth to the ED with a gunshot wound. For which early signs of hypovolemic shock does the nurse monitor? (Select all that apply.) a. Elevated serum potassium level b. Increase in heart rate c. Decrease in oxygen saturation d. Marked decrease in blood pressure e. Increase in respiratory rate

b, e

11. Which physiologic changes must the nurse teach an older adult who is taking medication to be aware of? (Select all that apply.) a. Oral drugs will be ineffective because of an age-related increase in GI motility. b. There may be an alterationin the ratio of adipose tissue to lean body mass, which may affect the distribution of a drug. c. Decreased function of the liver may alter the metabolism of certain drugs. d. Altered kidney function may affect excretion, causing increased plasma concentrations of drugs. e. Most older adults will not have any significant physiologic alterations.

b,c,d

6. Which assessment findings in the older adult indicate an increased risk for falls? (Select all that apply.) a. Increased mobility b. Macular degeneration c. Postural instability d. Full joint range of motion (ROM) e. Peripheral neuropathy

b,c,e

25. Which are considered the early signs of diabetic nephropathy? (Select all that apply.) a. Positive urine red blood cells b. Microalbuminuria c. Positive urine glucose d. Positive urine white blood cells e. Elevated serum uric acid

b,e

13. A patient at risk for shock has had some small, subtle changes in behavior within the past hour. How does the nurse evaluate the patient's mental status throughout the night? a. Assess the patient while he or she is awake, and then allow him or her to sleep until morning. b. Ask the patient and family to describe the patient's normal sleep and behavioral patterns. c. Periodically attempt to awaken the patient and document how easily he or she is aroused. d. Allow the patient to sleep, but assess respiratory effort and skin temperature.

14. In planning care for the older adult with dementia, the nurse identifies which intervention as the first priority goal of care? a. Prevent dognitive decline. b. Reorient on a regular basis. c. Prevent injuruy. d. Assist with ambulation.

15. A patient requires 100 g of oral glucose for suppression testing and GH levels are measured serially for 120 minutes. The results of the suppression testing are abnormal. The nurse assesses for the signs and symptoms of which endocrine disorder? a. Adrenal insufficiency b. DI c. Hyperpituitarism d. Hypothyroidism

16. Which phrase correctly describes palliative care? a. Care for patients with a prognosis of 6 months or less b. Diagnoses and treatment for patients with a life-threatening illness c. Patient care with a focus on treatment of symptoms d. Patient education about relevant treatment alternatives

17. A patient with blunt trauma to the abdomen has been NPO for several hours in preparation for a procedure and now reports subjective thirst. What is the nurse's first priority action? a. Get the a patient a few ice chips or a moistened swab b. Obtain on order for a stat hematocrit and hemoglobin c. Take the patient's vital signs and compare to baseline. d. Obtain on order to increase the IV rate.

17. Glucagon is used primarily to treat the patient with which disorder? a. DKA b. Idiosyncratic reaction to insulin c. Severe hypoglycemia d. HHNS

17. While caring for a patient of the orthodox Jewish faith who is dying, what cultural concept should the nurse keep in mind? a. Traditionally, Jewish cultures are male-dominant. b. Expression of grief is open, especially among women. c. An autopsy after death will not be permitted. d. Family members are likely to avoid visiting the terminally ill family member.

18. Which task should the nurse delegate to unlicensed assistive personnel (UAP) when caring for an older adult? a. Instruct the patient to drink at least 2 liters of fluids each day. b. Assess the patient's skin every 2 hours during repositioning. c. Assist the patient with feeding at meal times. d. Teach the patient to use incentive spirometry every hour while awake.

19. The unlicensed assistive personnel (UAP) reports repeatedly and unsuccessfully trying to take a patient's blood pressure with the electronic and manual devices. The nurse notes that the patient's apical pulse is elevated and the patient is at risk for hypovolemic shock. The patient begins to deteriorate. What is the best method for the nurse to determine the systolic blood pressure? a. Apply the electronic device to a lower extremity. b. Instruct the UAP to immediately get the Doppler. c. Apply the manual cuff and palpate for the systolic. d. Tell the UAP to try the electronic device on the other arm.

2. The terminally ill patient has an advance directive living will, which states that she does not want heroic measures such as cardiopulmonary resuscitation (CPR) and intubation. She also has a do not resuscitate order in her chart written by the provider. As the patient nears death, her daughter tells the hospice nurse that she wants everything possible done to save her mother's life. What is the nurse's best action? a. Call a code and bring the crash cart to the patient's bedside. b. Inform the health care provider of this change in the plan of care. c. Respect the patient's wishes and ask the chaplain to stay with the daughter. d. Inform the daughter that further interventions are futile.

2. Which statement is true about insulin? a. It is secreted by alpha cells in the islets of Langerhans. b. It is a catabolic hormone that builds up glucagon reserves. c. It is necessary for glucose transport across cell membranes. d. It is stored in muscles and converted to fat for storage.

22. The action of antidiuretic hormone (ADH) influences normal kidney function by stimulating which mechanism? a. Glomerulus to control the filtration rate b. Proximal nephron tubules to reabsorb water c. Distal nephron tubules and collecting ducts to reabsorb water d. Constriction of glomerular capillaries to prevent loss of protein in urine

23. A patient in hypovolemic shock is receiving sodium nitroprusside (Nitropress) to enhance myocardial perfusion. What is an important nursing implication for administering this drug? a. Assess the patient for headache because it is an early symptom of drug excess. b. Assess blood pressure at least every 15 minutes because hypertension is a symptom of overdose. c. Assess blood pressure at least every 15 minutes because systemic vasodilation can cause hypotension. d. Assess the patient every 30 minutes for extravasation because nitroprusside can cause severe vasoconstriction and tissue ishchemia.

29. Which class of antidiabetic medication should be given 1-30 minutes before meals? a. Alpha-glucosidase inhibitors, which include miglitol (Glyset) b. Biguanides, which include metformin (Glucophage) c. Meglitinides, which include nateglinide (Starlix) d. Second-generation sulfonylureas, which include glipizide (Glucotrol)

29. Which patient's history puts him or her at risk for developing SIADH? a. 27-year-old patient on high-dose steroids b. 47-year-old hospitalized adult patient with acute renal failure c. 58-year-old with metastatic lung or breast cancer d. Older adult with history of a stroke within the last year

30. A patient comes to the ED with severe injury and significant blood loss. The nurse anticipates that resuscitation will begin with which fluid? a. Whole blood b. 0.5% dextrose in water c. 0.9% sodium chloride d. Plasma protein fractions

30. Which oral agent may cause lactic acidosis? a. Nateglinide b. Repaglinide c. Metformin d. Miglitol

31. The effect of increased ADH in the blood results in which effect on the kidney? a. Urine concentration tends to decrease. b. Glomerular filtration tends to decrease. c. Tubular reabsorption of water increases. d. Tubular reabsorption of sodium increases.

34. Which statement about insulin administration is correct? a. Insulin may be given orally, intravenously, or subcutaneously. b. Insulin injections should be spaced no closer than one-half inch apart. c. Rotating injection sites improves absorption and prevents lipohypertrophy. d. Shake the bottle of intermediate-acting insulin, and then draw it into the syringe.

34. Which type of IV fluid does the nurse use to treat a patient with SIADH when the serum sodium level is very low? a. D5 1/2 normal saline b. D5W c. 3% normal saline d. Normal saline

35. The nurse is caring for an older adult patient at risk for shock. What is an early sign of shock in this patient? a. Cool, clammy skin b. Decreased urinary output c. Restlessness d. Hypotension

36. The nurse is caring for a patient with sepsis. At the beginning of the shift, the patient is in a hypodynamic state. Several hours later, the patient's blood pressure is elevated and pulse is bounding. How does the nurse interpret this change? a. A positive response and a signal of recovery b. Temporary situation that is likely to normalize c. Worsening of the condition rather than improvement d. Expected response to standard therapies

38. A 47-year-old patient with a history of type 2 DM and emphysema who reports smoking three packs of cigarettes per day is admitted to the hospital with a diagnosis of acute pneumonia. The patient is placed on the regular oral antidiabetic agents, sliding-scale insulin, and antibiotic medications. On day 2 of hospitalization, the health care provider orders prednisone therapy. What does the nurse expect the blood glucose to do? a. Decrease b. Stay the same c. Increase d. Return to normal

38. The nurse is caring for a patient at risk for sepsis. Why does the nurse closely monitor the patient for early signs of shock? a. The patient is unable to self-identify or report these early signs. b. Distributive shock usually begins as a bacterial or fungal infection. c. Prevention of septic shock is easier to achieve in the early phase. d. There is widespread vasodilation and pooling of blood in some tissues.

4. A patient receiving nursing care in a home hospice program can expect which kind of care? a. The use of high-technology equipment such as ventilators until time of death. b. Around-the-clock skilled direct nursing patient care until time of death. c. Pain and symptom management that will achieve the best quality of life. d. Complete relief of only distressing physical symptoms.

4. Which statement about how nutrition is affected in older adults is true? a. Changes in smell and taste can result in decreased use of sugar. b. Older adults need increased calorie intake to maintain ideal body weight. c. Loneliness and bordome may impact the older adult's incentive to eat. d. Obesity is the most common nutritional problem in nursing homes.

41. The nurse is caring for a patient at risk for septic shock from a wound infection. In order to prevent systemic inflammatory response syndrome, the nurse's priority is to monitor which factor? a. Patient's pulse rate and quality b. Patient's electrolyte imbalance c. Localized infected area d. Patient's intake and output

44. A patient receives dopamine 20 mcg/kg/min IV for the treatment of shock. What does the nurse assess for while administering this drug? a. Decreased urine output and decreased blood pressure b. Increased respiratory rate and increased urine output c. Chest pain and hypertension d. Bradycardia and headache

48. The nurse is reviewing the laboratory results of a patient with a systemic infection. What is the significance of a "left shift" in the differential leukocyte count? a. Expected finding because the patient has a serious infection. b. Indication that the infection is progressing towards resolution. c. Indication that the infection is outpacing the white cell production. d. Important to watch for trends, but otherwise not urgently significant.

49. The ICU nurse is caring for a patient with septic shock. Which IV infusion order for this patient does the nurse question? a. Antibiotics b. Insulin c. 10% dextrose in water d. Synthetic activated C protein

5. To qualify for hospice benefits, a criterion for admission is that the patient's prognosis must be limited to what amount of time? a. 2 weeks or less b. 3 months or less c. 6 months or less d. 1 year or less

50. The patient with diabetes has a foot that is warm, swollen, and painful. Walking causes the arch of the foot to collapse and gives the foot a "rocker bottom" shape. Which foot deformity does the nurse recognize? a. Hallux valgus b. Claw-toe deformity c. Charcot foot d. Diabetic foot ulcer

54. What is the recommended protocol for patients with type 2 DM who must lose weight? a. Participate in an aerobic program twice a week for 20 minutes each session. b. Slowly increase insulin dosage until mild hypoglycemia occurs. c. Reduce calorie intake moderately and increase exercise. d. Reduce daily calorie intake to 1000 calories and monitor urine for ketones.

58. The nurse is caring for a patient in septic shock with a serum glucose level of 280 mg/dL. What is the nurse's best interpretation of this finding? a. The patient is developing type 2 diabetes. b. The patient is developing type 1 diabetes. c. This finding is associated with a poor outcome. d. This finding is unexpected in septic shock.

71. The patient with DM had a pancreas transplant and takes daily doses of cyclosporine (Neoral). For which key lab assessment does the nurse monitor? a. Serum electrolytes b. CBC with differential count c. Serum creatinine d. Clotting studies

75. A patient has been receiving insulin in the abdomen for 3 days. On day 4, where does the nurse give the insulin injection? a. Deltoid b. Thigh c. Abdomen, but in an area different from the previous day's injection d. Abdomen, in the same area as the previous day's injection

8. Which patient is at risk for obstructive shock? a. Patient with a history of angina b. Patient with chronic atrial fibrillation c. Patient with a pulmonary embolus d. Patient with a history of heart failure

9. A patient has cardiac dysrhythmias and pulmonary problems as a result of receiving an IV antibiotic. What type of shock does the nurse recognize this present? a. Hyhpovolemic b. Cardiogenic c. Anaphylactic d. Septic

Iggy Study Guide Ch.59 3. Which patient is at low risk for the developmetn of gallbladder disorders? a. Patient with sickle cell anemia b. Patient who is Mexican American c. Patient who is 20 years old and male d. Patient with a history of prolonged parenteral nutrition

Iggy Study Guide Ch.59 30. What is the most common and serious complication after a Whipple procedure? a. Diabetes mellitus b. Wound infection c. Fistula development d. Bowel obstruction

Iggy Study Guide Ch.59 6. The nurse is assessing a patient with acute cholecystitis whose abdominal pain is severe. The patient has a heart rate of 118/minute, is pale, diaphoretic, and describes extreme fatigue. What is the nurse's priority action at this time? a. Instruct the UAP to check a complete set of vital signs. b. Auscultate the patient's abdomen in all four quadrants. c. Notify the patient's health care provider. d. Administer the ordered opioid analgesic.

Question 18 of 26 A dying client says to the nurse, "I am afraid to die. I did a lot of wrong things in my life." How does the nurse respond? a. "Don't worry, God will forgive you." b. "I'm sure it is nothing to worry about." c. "Tell me more about that." d. "Why? What did you do wrong?"

c "Tell me more about that." A response such as, "Tell me more about that," acknowledges the client's spiritual pain and encourages verbalization. "Don't worry, God will forgive you" assumes that the client is religious and minimizes the client's concerns; it gives false reassurance and is a nontherapeutic response. Saying that it's nothing to worry about minimizes the client's concerns and is a nontherapeutic response; it shuts the client off from expressing his or her concerns. Asking why the client is afraid and what he or she did wrong assumes that the client did something wrong, which may not be the case. "Why" questions are never considered to be therapeutic because they place clients on defense; they often stop communication.

Question 1 of 26 The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life? a. "Do you believe in God?" b. "Tell me about the history of religion in your life." c. "What gives you purpose and meaning in your life?" d. "Where have you been attending church for the past several years?"

c "What gives you purpose and meaning in your life?" Spirituality is whatever or whoever gives ultimate meaning in one's life. It is not necessarily God, but it could be. It could be the client's definition of a higher power. The client may not believe in God and may find an inquiry about believing in God offensive and judgmental. Religion is affiliation or membership in a faith community; its members may be supportive of the client if the client is a member of a religious community, but this is not the best way to determine what the client's spirituality is. Church attendance is one way that some individuals express their religion, but it does not necessarily define a person's spirituality; asking about church could place the client on defense.

10. Which of these clients with diabetes does the endocrine unit charge nurse assign to an RN who has floated from the labor/delivery unit? a. A 58-year-old with sensory neuropathy who needs teaching about foot care b. A 68-year-old with diabetic ketoacidosis who has an IV running at 250 mL/hr c. A 70-year-old who needs blood glucose monitoring and insulin before each meal d. A 76-year-old who was admitted with fatigue and shortness of breath

c A nurse from the labor/delivery unit would be familiar with blood glucose monitoring and insulin administration because clients with type 1 and gestational diabetes are frequently cared for in the labor/delivery unit. The 58-year-old with sensory neuropathy, the 68-year-old with diabetic ketoacidosis, and the 76-year-old with fatigue and shortness of breath all have specific teaching or assessment needs that are better handled by nurses more familiar with caring for older adults with diabetes.

1. A diabetic client has a glycosylated hemoglobin (HbA1C) level of 9.4%. What does the nurse say to the client regarding this finding? a. "Keep up the good work." b. "This is not good at all." c. "What are you doing differently?" d. "You need more insulin."

c Assessing the client's regimen or changes he or she may have made is the basis for formulating interventions to gain control of blood glucose. HbA1C levels for diabetic clients should be less than 7%; a value of 9.4% shows poor control over the past 3 months. Telling the client this is not good, although true, does not take into account problems that the client may be having with the regimen and sounds like scolding. Although it may be true that the client needs more insulin, an assessment of the client's regimen is needed before decisions are made about medications.

6. A client with type 2 diabetes has been admitted for surgery, and the health care provider has placed the client on insulin in addition to the current dose of metformin (Glucophage). The client wants to know the purpose of taking the insulin. What is the nurse's best response? a. "Your diabetes is worse, so you will need to take insulin." b. "You can't take your metformin while in the hospital." c. "Your body is under more stress, so you'll need insulin to support your medication." d. "You must take insulin from now on because the surgery will affect your diabetes."

c Because of the stress of surgery and NPO status, short-term insulin therapy may be needed perioperatively for the client who uses oral antidiabetic agents. For those receiving insulin, dosage adjustments may be required until the stress of surgery subsides. No evidence suggests that the client's diabetes has worsened; however, surgery is stressful and may increase insulin requirements. Metformin may be taken in the hospital; however, not on days when the client is NPO for surgery. When the client returns to his or her previous health state, oral agents will be resumed.

Question 10 of 10 Emergency Medical Services arrives at the scene of an automobile crash. On primary assessment, the driver is found to be unresponsive, not breathing, and bleeding profusely. What is the first resuscitation intervention to be performed? a. Apply pressure to the bleeding. b. Carry out artificial respirations. c. Clear the airway. d. Place a cervical collar.

c Clear the airway. Even minutes without an adequate oxygen supply in humans can lead to cerebral injury, and can progress to anoxic brain death. The airway should be cleared of any secretions or debris with a suction catheter or manually, if necessary. Applying pressure to wounds and placing a cervical collar are important, but neither is the priority. Commencing with artificial respiration is important, but the airway must be cleared first.

Review Questions - NCLEX® Examination - Chapter 37 Question 20 of 26 The nurse is caring for a client in the refractory stage of cardiogenic shock. Which intervention does the nurse consider? a. Admission to rehabilitation hospital for ambulatory retraining b. Collaboration with home care agency for return to home c. Discussion with family and provider regarding palliative care d. Enrollment in a cardiac transplantation program

c Discussion with family and provider regarding palliative care In this irreversible phase, therapy is not effective in saving the client's life, even if the cause of shock is corrected and mean arterial pressure temporarily returns to normal. A discussion on palliative care should be considered. Rehabilitation or returning home is unlikely. The client with sustained tissue hypoxia is not a candidate for organ transplantation.

Question 13 of 26 A Christian client is struggling with a diagnosis of cancer and says, "Why is life so unfair?" What health care team member does the nurse ask to provide support? a. Client's family b. Physician c. Hospital chaplain d. Psychiatrist

c Hospital chaplain Chaplains have the time and expertise to manage spiritual distress, no matter what the client's religious preference. The family is not a member of the health care team. Asking the physician to provide support is inappropriate. Asking the psychiatrist for support might make sense, but is not the best answer.

4. The assessment findings of a male patient with anterior pituitary tumor include reports of changes in secondary sex characteristics, such as episodes of impotence and decreased libido. The nurse explains to the patient that these findings are a result of overproduction of which hormone? a. Gonadotropins inhibiting prolactin (PRL) b. Thyroid hormone inhibiting PRL c. PRL inhibiting secretion of gonadotropins d. Steroids inhibiting production of sex hormones

c PRL inhibiting secretion of gonadotropins

23. Which explanation best assists a client in differentiating type 1 diabetes from type 2 diabetes? a. Most clients with type 1 diabetes are born with it. b. People with type 1 diabetes are often obese. c. Those with type 2 diabetes make insulin, but in inadequate amounts. d. People with type 2 diabetes do not develop typical diabetic complications.

c People with type 2 diabetes make some insulin but in inadequate amounts, or they have resistance to existing insulin. Although type 1 diabetes may occur early in life, it may be caused by immune responses. Obesity is typically associated with type 2 diabetes. People with type 2 diabetes are at risk for complications, especially cardiovascular complications.

Review Questions - NCLEX® Examination - Chapter 37 Question 8 of 26 Which problem places a client at highest risk for sepsis? a. Pernicious anemia b. Pericarditis c. Post kidney transplant d. Client owns an iguana

c Post kidney transplant The post-kidney transplant client will need to take lifelong immune suppressant therapy and is at risk for infection from internal and external organisms. Pernicious anemia is related to lack of vitamin B12, not to bone marrow failure (aplastic anemia), which would place the client at risk for infection. Inflammation of the pericardial sac is an inflammatory condition that does not pose a risk for septic shock. Although owning pets, especially cats and reptiles, poses a risk for infection, the immune-suppressed kidney transplant client has a very high risk for infection, sepsis, and death.

15. Which action is correct when drawing up a single dose of insulin? a. Wash hands thoroughly and don sterile gloves. b. Shake the bottle of insulin vigorously to mix the insulin. c. Pull back plunger to draw air into the syringe equal to the insulin dose. d. Recap the needle and save the syringe for the next dose of insulin.

c Pull back plunger to draw air into the syringe equal to the insulin dose. The plunger is pulled back to draw an amount of air into the syringe that is equal to the insulin dose. The air is then injected into the insulin bottle before withdrawing the insulin dose. Although handwashing is important before any medication administration, sterile gloves are not required. The bottle of insulin should be rolled gently in the palms of the hands to mix the insulin, not shaken. Insulin syringes are never recapped or reused; the syringe and needle should be disposed of (without recapping) in a puncture-proof container.

NCLEX® Examination Challenges IGGY Ch.64 p. 1306, Physiological Integrity Which health problems are considered results of microvascular complications from long-term or poorly controlled diabetes mellitus? A. Obesity and hyperglycemia B. Systolic hypertension and heart failure C. Retinal hemorrhage and male erectile dysfunction D. Diabetic ketoacidosis and hyperglycemic-hyperosmolar state

c Rationale: Both retinal hemorrhage and male erectile dysfunction are caused by microvascular complications. Structural problems in retinal vessels include areas of poor retinal circulation, edema, hard fatty deposits in the eye, and retinal hemorrhages. Microvascular changes cause hypoxia and death of the nerves needed for male erection. Systolic hypertension and heart failure are considered macrovascular complications. Obesity and hyperglycemia are causes of microvascular complications and are not caused by them. Diabetic ketoacidosis and hyperglycemic-hyperosmolar state are problems of hyperglycemia but are not caused by microvascular changes.

2. A client expresses fear and anxiety over the life changes associated with diabetes, stating, "I am scared I can't do it all and I will get sick and be a burden on my family." What is the nurse's best response? a. "It is overwhelming, isn't it?" b. "Let's see how much you can learn today, so you are less nervous." c. "Let's tackle it piece by piece. What is most scary to you?" d. "Other people do it just fine."

c Suggesting the client tackle it piece by piece and asking what is most scary to him or her is the best response; this approach will allow the client to have a sense of mastery with acceptance. Referring to the illness as overwhelming is supportive, but is not therapeutic or helpful to the client. Trying to see how much the client can learn in one day may actually cause the client to become more nervous; an overload of information is overwhelming. Suggesting that other people handle the illness just fine is belittling and dismisses the client's concerns.

Review Questions - NCLEX® Examination - Chapter 37 Question 25 of 26 What typical sign/symptom indicates the early stage of septic shock? a. Pallor and cool skin b. Blood pressure 84/50 mm Hg c. Tachypnea and tachycardia d. Respiratory acidosis

c Tachypnea and tachycardia Signs of systemic inflammatory response syndrome, which precedes sepsis, include rapid respiratory rate, leukocytosis, and tachycardia. In the early stage of septic shock, the client is usually warm and febrile. Hypotension does not develop until later in septic shock due to compensatory mechanisms. Respiratory alkalosis occurs early in shock because of an increased respiratory rate.

13. Which statement about hormone replacement therapy for hypopituitarism is correct? a. Once manifestations of hypofunction are corrected, treatment is no longer needed. b. The most effective route of androgen replacement is the oral route. c. Testosterone replacement is contraindicated in men with prostate cancer. d. Clomiphene citrate (Clomid) is used to to suppress ovulation in women.

c Testosterone replacement is contraindicated in men with prostate cancer.

13. An intensive care client with diabetic ketoacidosis (DKA) is receiving an insulin infusion. The cardiac monitor shows ventricular ectopy. Which assessment does the nurse make? a. Urine output b. 12-lead electrocardiogram (ECG) c. Potassium level d. Rate of IV fluids

c With insulin therapy, serum potassium levels fall rapidly as potassium shifts into the cells. Detecting and treating the underlying cause is essential. Insulin treats symptoms of diabetes by putting glucose into the cell as well as potassium; ectopy, indicative of cardiac irritability, is not associated with changes in urine output. A 12-lead ECG can verify the ectopy, but the priority is to detect and fix the underlying cause. Increased fluids treat the symptoms of dehydration secondary to DKA, but do not treat the cause.

15. The nurse is caring for a patient at risk for hypovolemic shock. For which indicators of shock does the nurse monitor? (Select all that apply.) a. Elevated body temperature b. Increased peristalsis c. Decreasing urine output d. Vasodilation e. Increasing heart rate

c, e

2. A malfunctioning posterior pituitary gland can result in which disorders? (Select all that apply.) a. Hypothyroidism b. Altered sexual function c. Diabetes insipidus (DI) d. Growth retardation e. Syndrome of inappropriate antidiuretic hormone (SIADH)

c, e Diabetes insipidus Syndrome of inappropriate antidiuretic hormone (SIADH)

57. The nurse is teaching a patient with diabetes about proper foot care. Which instructions does the nurse include? (Select all that apply.) a. Use rubbing alcohol to toughen the skin on the soles of the feet. b. Wear open-toed shoes or sandals in warm weather to prevent perspiration. c. Apply moisturizing cream to the feet after bathing, but not between the toes. d. Use cold water for bathing the feet to prevent inadvertent thermal injury. e. Do not go barefoot. f. Inspect the feet daily.

c, e, f

8. Which statements about the assessment of a terminally ill patient are true? (Select all that apply.) a. Assess only the patient; do not include the family's perception of the patient's symptoms. b. When the patient is unable to communicate, there is no need to assess symptoms of distress any longer. c. Assess patients who are unable to communicate distress by observing for objective signs of discomfort. d. Assess the patient for dyspnea, agitation, nausea, and vomiting only. e. Identify alternative methods to assess for symptoms of distress. f. The family can help identify patient habits and preferences, which may aid in the overall assessment.

c, e, f

48. Which statements about sensory alteration in patients with diabetes are accurate? (Select all that apply.) a. Healing of foot wounds is reduced because of impaired sensation. b. Very few patients with diabetic foot ulcers have peripheral sensory neuropathy. c. Loss of pain, pressure, and temperature sensation in the foot increases the risk for injury. d. Sensory neuropathy causes loss of normal sweating and skin temperatures regulation. e. It can be delayed by keeping the blood glucose level as close to normal as possible.

c,d,e

39. A patient has a localized infection. What assessment findings are considered evidence of a beneficial inflammatory response? a. Decreased urine output which normalizes after fluid bolus b. Pulse rate of 120 beats/min related to increased metabolic activity c. Decreased oxygen saturation which responds to supplemental O2 d. Redness and edema that appear but subside in several days

39. The nurse expects to perform which diagnostic test for pheochromocytoma? a. 24-hour urine collection for sodium, potassium, and glucose b. Catecholamine-stimulation test c. Administration of beta-adrenergic blocking agent and monitor results. d. 24- hour urine collection for fractionated metanephrine and catecholamine levels.

39. Which laboratory test is the best indicator of a patient's average blood glucose level and/or compliance with the DM regimen over the last 3 months? a. Postparandial blood glucose test b. Oral glucose tolerance test (OGTT) c. Casual blood glucose test d. Glycosylated hemoglobin (HbA1c)

4. Which statement about the systemic effects of shock is correct? a. The liver is essentially unaffected, but liver enzymes may be lower than normal. b. The current heart rate and blood pressure indicate cardiac system is at baseline. c. The brain and neurologic system can withstand 10 to 15 minutes of severe hypoperfusion. d. The kidneys can tolerate hypoxia and anoxia up to 1 hour without permanent damage.

40. The student nurse is assessing a patient's mental status because of the patient's risk for decreased tissue perfusion. The supervising nurse intervenes when the student nurse asks the patient which question? a. "What is today's date?" b. "Who is the president of this country?" c. "Where are we right now?" d. "Is your name Mr. John Smith?"

42. A patient with type 2 DM, usually controlled with a second-generation sulfonylurea, develops a urinary tract infection. Due to the stress of the infection, the patient must be treated with insulin. What additional information about this treatment does the nurse relay to the patient? a. The sulfonylurea must be discontinued and insulin taken until the infection clears. b. Insulin will now be necessary to control the patient's diabetes for life. c. The sulfonylurea does must be reduced until the infection clears. d. The insulin is necessary to supplement the second-generation sulfonylurea until the infection clears.

42. The nurse is evaluating the care and treatment for a patient in shock. Which finding indicates that the patient is having an appropriate response to the treatment? a. Blood pH of 7.28 b. Arterial Po2 of 65 mm Hg c. Distended neck veins d. Increased urinary output

42. Which diuretic is ordered by the health care provider to treat hyperaldosteronism? a. Furosemide (Lasix) b. Ethacrynic acid (Edecrin) c. Bumetanide (Bumex) d. Spironolactone (Aldactone)

43. Which statement about hyperaldosteronism is correct? a. Painful "charley horses" are common from hyperkalemia. b. It occurs more often in men than in women. c. It is a common cause of hypertension in the population. d. Hypokalemia and hypertension are the main issues.

44. When diagnosed with Cushing's syndrome, the manifestations are most likely related to an excess production of which hormone? a. Insulin from the pancreas b. ADH from posterior pituitary gland c. PRL from anterior pituitary gland d. Cortisol from the adrenal cortex

45. A patient will be using an external insulin pump. What does the nurse tell the patient about the pump? a. SMBG levels can be done only twice a day. b. The insulin supply must be replaced every 2 to 4 weeks. c. The pump's battery should be checked on a regular weekly schedule. d. The needle must be changed every two to three days.

45. What is the most common cause of endogenous hypercortisolism, or Cushing's disease? a. Pituitary hypoplasia b. Insufficient ACTH production c. Adrenocortical hormone deficiency d. Hyperplasia of the adrenal cortex

47. The ICU nurse observes petechiae, ecchymoses, and blood oozing from gums and other mucous membranes of a patient with septic shock. How does the nurse interpret this finding? a. Pulmonary emboli (PE) b. Acute respiratory distress syndrome (ARDS) c. systemic inflammatory response syndrome (SIRS) d. Disseminated intravascuolaar coagulation (DIC)

51. A patient is at risk for sepsis. Which assessment finding is most indicative of the hyperdymanic activity that occurs in septic shock? a. Crackles in lung bases b. Weak, rapid peripheral pulses c. Cool, clammy, cyanotic skin d. Increaed pulse rate with warm, pink skin

52. The nurse is teaching a patient being discharged after bilateral adrenalcectomy. What medication information does the nurse emphasize in the teaching plan? a. The dosage of steroid replacement drugs will be consistent throughout the patient's lifetime. b. The steroid drugs should be taken in the evening so as not to interfere with sleep. c. The patient should take the drugs on an empty stomach. d. The patient should learn how to give himself an intramuscular injection of hydrocortisone.

52. What is the basic principle of meal planning for a patient with type 1 DM? a. Five small meals per day plus a bedtime snack b. Taking extra insulin when planning to eat sweet foods c. High-protein, low-carbohydrate, and low-fiber foods d. Considering the effects and peak action times of the patient's insulin

54. A 70-year-old man is admitted to the hospital with an infected finger of several days' duration. He is lethargic, confused, and has a temperature of 101.3F. Othera ssessment findings include blood pressure of 94/50 mm Hg, pulse 105 beats/min, respirations 40, and shallow breathing. Pulmonary arterial wedge pressure (PAWP) is 4 mm Hg. These assessment findings indicate what type of shock? a. Hypovolemic b. Cardiogenic c. Anaphylactic d. Septic

58. A 25-year-old female patient with type 1 DM tells the nurse, "I have two kidneys and I'm still young. I expect to be around for a long time, so why should I worry about my blood sugar?" What is the nurse's best response? a. "You have little to worry about as long as your kidneys keep making urine." b. "You should discuss this with your physician because you are being unrealistic." c. "You would be right if your diabetes was managed with insulin." d. "Keeping your blood sugar under control now can help to prevent damage to both kidneys."

69. A patient with type 1 DM is taking a mixture of NPH and regular insulin at home. The patient has been NPO for surgery since midnight. What action does the nurse take regarding the patient's morning dose of insulin? a. Administer the dose that is routinely prescribed at home because the patient has type 1 Dm and needs the insulin. b. Administer half the dose because the patient is NPO. c. Hold the insulin with all the other medications because the patient is NPO and there is no need for insulin. d. Contact the health care provider for an order regarding the insulin.

7. According to the American Diabetes Association (ADA), which laboratory finding is most indicative of DM? a. Fasting blood glucose = 80 mg/dL b. 2-hour postprandial blood glucose = 110 mg/dL c. 1-hour glucose tolerance blood glucose = 110 mg/dL d. 2-hour glucose tolerance blood glucose = 210 mg/dL

74. A patient with diabetes has signs and symptoms of hypoglycemia. The patient has a blood glucose of 56 mg/dL, is not alert but responds to voice, and is confused and is unable to swallow fluids. What does the nurse do next? a. Give a glass of orange juice with two packets of sugar and continue to monitor the patient. b. Give a glass of orange or other type of juice and continue to monitor the patient. c. Give a complex carbohydrate and continue to monitor the patient. d. Administer D50 IV push.

79. The male diabetic patient asks the nurse for advice about alcohol consumption. What is the nurse's best response? a. "It is best to have alcohol near bedtime." b. "As long as your diabetes is under control you can drink as much as you like." c. "You should drink only one alcoholic beverage with each meal." d. "Avoid more than two drinks a day and have them with or shortly after meals."

8. Untreated hyperglycemia results in which condition? a. Respiratory acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Metabolic acidosis

Iggy Study Guide Ch.59 9. Which type of drug is used to treat acute severe biliary pain? a. Acetaminophen (Tylenol) b. Nonsteroidal antiinflammatory drugs (NSAIDs)(Ibuprofen) c. Antiemetics (Compazine) d. Opiodis (Morphine)

Question 8 of 26 The family of an unconscious dying client realizes that their mother will die soon. The client's children are having a difficult time letting go. How does the nurse respond to the needs of this family? a. "Don't be upset; she wouldn't want it that way." b. "She will soon be in a better place." c. "Things will be fine, try not to worry so much." d. "This must be difficult for you."

d "This must be difficult for you." Accept whatever the grieving person says about the situation. Remain present, be ready to listen attentively, and guide gently. In this way, the nurse can help the bereaved prepare for the necessary reminiscence and integration of the loss. The client's or family member's pain of loss should never be minimized. Trite assurances such as saying, "Don't be upset; she wouldn't want it that way" or "Things will be fine," should be avoided. Such comments can actually be barriers to demonstrating care and concern. Never try to explain a client's death or impending death in philosophic or religious terms; such statements are not helpful when the bereaved person has yet to express feelings of anguish or anger.

Review Questions - NCLEX® Examination - Chapter 37 Question 16 of 26 Which problem places a person at highest risk for septic shock? a. Kidney failure b. Cirrhosis c. Lung cancer d. 40% burn injury

d 40% burn injury The skin forms the first barrier to prevent entry of organisms into the body; this client is at very high risk for sepsis and death. Although the client with kidney failure has an increased risk for infection, his skin is intact, unlike the client with burn injury. Although the liver acts as a filter for pathogens, the client with cirrhosis has intact skin, unlike the burned client. The client with lung cancer may be at risk for increased secretions and infection, but risk is not as high as for a client with open skin.

3. The nurse receives report on a 52-year-old client with type 2 diabetes:Physical AssessmentDiagnostic FindingsProvider PrescriptionsLungs clearGlucose 179 mg/dLRegular insulin 8 units if blood glucose 250 to 275 mg/dL and cold to touchRight great toe mottledHemoglobin A1c 6.9%Regular insulin 10 units if glucose 275 to 300 mg/dLClient states wears eyeglasses to readWhich complication of diabetes does the nurse report to the provider? a. Poor glucose control b. Visual changes c. Respiratory distress d. Decreased peripheral perfusion

d A cold, mottled toe may indicate arterial occlusion secondary to arterial occlusive disease or embolization; this must be reported to avoid potential gangrene and amputation. Although one glucose reading is elevated, the hemoglobin A1c indicates successful glucose control over the past 3 months. After the age of 40, reading glasses may be needed due to difficulty in accommodating to close objects. Lungs are clear and no evidence of distress is noted.

22. Which nursing action can the home health nurse delegate to a home health aide who is making daily visits to a client with newly diagnosed type 2 diabetes? a. Assist the client's spouse in choosing appropriate dietary items. b. Evaluate the client's use of a home blood glucose monitor. c. Inspect the extremities for evidence of poor circulation. d. Assist the client with washing the feet and applying moisturizing lotion.

d Assisting with personal hygiene is included in the role of home health aides. Assisting with dietary choices, evaluating the effectiveness of teaching, and performing assessments are complex actions that should be implemented by licensed nurses.

Review Questions - NCLEX® Examination - Chapter 37 Question 23 of 26 A client with hypovolemic shock has these vital signs: temperature 97.9° F; pulse 122 beats/min; blood pressure 86/48 mm Hg; respirations 24 breaths/min; urine output 20 mL for last 2 hours; skin cool and clammy. Which medication order for this client does the nurse question? a. Dopamine (Intropin) 12 mcg/kg/min b. Dobutamine (Dobutrex) 5 mcg/kg/min c. Plasmanate 1 unit d. Bumetanide (Bumex) 1 mg IV

d Bumetanide (Bumex) 1 mg IV A diuretic such as bumetanide will decrease blood volume in a client who is already hypovolemic; this order should be questioned because this is not an appropriate action to expand the client's blood volume. The other orders are appropriate for improving blood pressure in shock, and do not need to be questioned.

1. Problems in the hypothalamus that change the function of the anterior pituitary gland result in which condition? a. Adenohypophysis b. Panhypopituitarism c. Primary pituitary dysfunction d. Secondary pituitary dysfunction

d Secondary pituitary dysfunction

Review Questions - NCLEX® Examination - Chapter 37 Question 1 of 26 When caring for an obtunded client admitted with shock of unknown origin, which action does the nurse take first? a. Obtain IV access and hang prescribed fluid infusions. b. Apply the automatic blood pressure cuff. c. Assess level of consciousness and pupil reaction to light. d. Check the airway and respiratory status.

d Check the airway and respiratory status. When caring for any client, determining airway and respiratory status is the priority. The airway takes priority over obtaining IV access, applying the blood pressure cuff, and assessing for changes in the client's mental status.

Question 20 of 26 The nurse is coordinating interdisciplinary palliative care interventions for the dying client. Which goal is the nurse seeking to meet? a. Avoiding symptoms of client distress b. Ensuring an expedited death c. Meeting all of the client's needs d. Facilitating a peaceful death for the client

d Facilitating a peaceful death for the client Facilitating a peaceful death for the client is one of the goals of palliative care. Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client's needs (e.g., to prevent death or lengthen life).

7. Patients diagnosed with an anterior pituitary tumor can have symptoms of acremegaly or gigantism. These symptoms are a result of overproduction of which hormone? a. ACTH b. PRL c. Gonadotropins d. GH

d GH

Question 6 of 26 Which condition, when assessed in a dying client, requires that the nurse take action? a. Alternating apnea and rapid breathing b. Anorexia c. Cool extremities d. Moaning

d Moaning Moaning indicates pain and requires pain medication. Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the dying client.

Question 5 of 10 A client is admitted to the emergency department after being in a motor vehicle crash. The client was wearing a seat belt and the airbag deployed. There are no apparent injuries besides an abrasion from the shoulder harness across the clavicle and anterior chest. First vital signs are BP 110/70, HR 98, R 18, SaO2 98% on room air. The client's Glasgow Coma Scale score is 15. What does the nurse do next? a. Allows the client to go home b. Checks blood alcohol levels c. Prepares the client for surgery d. Monitors the client

d Monitors the client Blunt trauma results from impact forces. The energy transmitted from a blunt trauma mechanism, particularly the rapid acceleration-deceleration forces involved in high-speed crashes or falls from a great height, produce injury by tearing, shearing, and compressing anatomic structures. Injury may not be evident right away. A seat belt abrasion across the chest should alert the nurse to monitor closely for signs of potential internal injuries. Allowing the client to leave is not the best course of action because complications could still occur. No evidence in this scenario suggests that the client was drinking. There is no indication from the scenario that surgical intervention is required.

12. In reviewing the health care provider admission requests for a client admitted in a hyperglycemic-hyperosmolar state, which request is inconsistent with this diagnosis? a. 20 mEq KCl for each liter of IV fluid b. IV regular insulin at 2 units/hr c. IV normal saline at 100 mL/hr d. 1 ampule NaHCO3 IV now

d NaHCO3 is given for the acid-base imbalance of diabetic ketoacidosis, not the hyperglycemic-hyperosmolar state, which presents with hyperglycemia and absence of ketosis/acidosis. KCl 20 mEq for each liter of IV fluid will correct hypokalemia from diuresis. IV regular insulin at 2 units/hr will correct hyperglycemia. IV normal saline at 100 mL/hr will correct dehydration.

Question 23 of 26 A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention does the nurse implement? a. Brings in the client's favorite Chinese takeout food b. Calls the family to come in right away c. Gives intravenous hydration d. Offers ice chips

d Offers ice chips The dying client should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth." The dying client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not necessary at this point.

NCLEX® Examination Challenges IGGY Ch.64 p. 1302, Physiological Integrity How is hypoglycemia prevented in the healthy person who does not have diabetes even after fasting for 8 hours? A. Metabolism is so slow when a person sleeps without eating for 8 hours that blood glucose does not enter cells to be used for energy. As a result, hypoglycemia does not occur. B. Fasting for 8 hours triggers conversion of proteins into glycogen (glycogenesis) so that hyperglycemia develops rather than hypoglycemia. C. Lipolysis (fat breakdown) in fat stores occurs, converting fatty acids into glucose to maintain blood glucose levels. D. The secretion of glucagon prevents hypoglycemia by promoting glucose release from liver storage sites.

d Rationale: Glucagon is a counterregulatory hormone secreted by pancreatic alpha cells when blood glucose levels are low, as they would be during an 8-hour fast. The body's metabolic rate does decrease during sleep (which is not stated in this question) but not sufficiently to prevent hypoglycemia. Glucagon works on the glycogen stored in the liver, breaking it down to glucose (glycogenolysis) molecules that are then released into the blood to maintain blood glucose levels and prevent hypoglycemia. Although proteins can be broken down and converted to glucose, they are not converted to glycogen. Fat breakdown through lipolysis can provide fatty acids for fuel, but this is not glucose, and lipolysis does not occur until all stored glycogen is used.

Question 4 of 26 A hospice client has just died. Which of these postmortem nursing tasks is most appropriate to delegate to a nursing assistant? a. Assessing the client for cessation of respiratory effort and lack of pulse b. Documenting the time of death and required assessment data on the chart c. Notifying the spouse and other family members about the client's death d. Removing or cutting all IV lines or tubes according to the hospice policy

d Removing or cutting all IV lines or tubes according to the hospice policy Preparing the body for viewing by the family (such as removing tubing and lines) and/or transfer to the morgue is an appropriate task for unlicensed assistive personnel. Assessing for signs of life, documenting about the death, and spousal and family notification all require broader education and should be done by licensed nursing staff.

Question 17 of 26 A client dying of cancer is receiving high doses of opioids. In addition, which intervention is the most effective for this client? a. Classical music b. Deep muscle massage c. More pain medication d. Short, light massage

d Short, light massage Massage has been shown to decrease pain in individuals with cancer. Light pressure is best, and deep or intense pressure should be avoided. Although music therapy may be effective, the type of music played should be the client's choice; it should not be assumed that the client wants to hear classical music. The dying client who is frail may not tolerate an extensive deep massage. The client is already receiving high doses of opioids; complementary or alternative therapy can replace the need for increased pain medication.

Question 14 of 26 In a comatose dying client's hospital room, the nurse overhears family discussing the memorial service. What action does the nurse take? a. Asks the family to speak in low tones or whispers so as not to disturb the client b. Offers to call and have a hospital chaplain come and discuss plans with them c. Shares some personal insights and experiences on planning a meaningful memorial service d. Suggests that the family leave the room to carry on their discussion

d Suggests that the family leave the room to carry on their discussion Discussions about the client should not be carried on while the family is in the client's room. Hearing is the last of the senses to leave dying clients, and it is believed that the client can hear even whispers until the end of his or her life. The family needs to have their discussion elsewhere. The chaplain may be helpful to the family, but the discussion still needs to happen outside of the hospital room. It is not at all appropriate for the nurse to interact with the family about planning for a service, especially within hearing range of the client.

Review Questions - NCLEX® Examination - Chapter 37 Question 21 of 26 The nurse is caring for postoperative clients at risk for hypovolemic shock. Which condition represents an early symptom of shock? a. Hypotension b. Bradypnea c. Heart blocks d. Tachycardia

d Tachycardia Heart and respiratory rates increased from the client's baseline level or a slight increase in diastolic blood pressure may be the only objective manifestation of this early stage of shock. Catecholamine release occurs early in shock as a compensation for fluid loss; blood pressure will be normal. Early in shock, the client displays rapid, not slow, respirations. Dysrhythmias are a late sign of shock; they are related to lack of oxygen to the heart.

Question 11 of 26 A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? a. Administers nutrition and fluids through a nasogastric tube b. Explains to the family that aspiration may be a concern c. Obtains a physician order to initiate an IV line d. Teaches the family how to provide oral care

d Teaches the family how to provide oral care Because the oral mucosa will become dry, family members should be taught how to moisten the lips and mouth. Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client's suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing.

5. A client recently admitted with new-onset type 2 diabetes will be discharged with a self-monitoring blood glucose machine. When is the best time for the nurse to explain to the client the proper use of the machine? a. Day of discharge b. On admission c. When the client states readiness d. While performing the test in the hospital

d Teaching the client about the operation of the machine while performing the test in the hospital is the best way for the client to learn. The teaching can be reinforced before discharge. Instructing the client on the day of admission or the day of discharge would be overwhelming to the client because of all of the other activities taking place on those days. The client may never feel ready to learn this daunting task; the nurse must be more proactive.

Review Questions - NCLEX® Examination - Chapter 37 Question 13 of 26 Which nurse should be assigned to care for an intubated client who has septic shock as the result of a methicillin-resistant Staphylococcus aureus (MRSA) infection? a. The LPN/LVN who has 20 years of experience b. The new RN who recently finished orienting and is working independently with moderately complex clients c. The RN who will also be caring for a client who had coronary artery bypass graft (CABG) surgery 12 hours ago d. The RN with 2 years of experience in intensive care

d The RN with 2 years of experience in intensive care The RN with current intensive care experience who is not caring for a postoperative client would be an appropriate assignment. Care of the unstable client with intubation and mechanical ventilation is not within the scope of practice for the LPN/LVN. A client who is experiencing septic shock is too complex for the new RN. Although the RN who is also caring for the post-CABG client is experienced, this assignment will put the post-CABG client at risk for MRSA infection.

25. A client with type 2 diabetes who is taking metformin (Glucophage) is seen in the diabetic clinic. The fasting blood glucose is 108 mg/dL, and the glycosylated hemoglobin (HbA1C) is 8.2%. Which action does the nurse plan to take next? a. Instruct the client to continue with the current diet and metformin use. b. Discuss the need to check blood glucose several times every day. c. Talk about the possibility of adding rapid-acting insulin to the regimen. d. Ask the client about current dietary intake and medication use.

d The nurse's first action should be to assess whether the client is adherent to the currently prescribed diet and medications. The client's current diet and medication use have not been successful in keeping glucose in the desired range. Checking blood glucose more frequently and/or using rapid-acting insulin may be appropriate, but this will depend on the assessment data. The HbA1C indicates that the client's average glucose level is not in the desired range, but discussing the need to check blood glucose several times every day assumes that the client is not compliant with the therapy and glucose monitoring. The nurse should not assume that adding insulin, which must be prescribed by the provider, is the answer without assessing the underlying reason for the treatment failure.

Question 4 of 10 There has been an explosion at a local refinery. Numerous serious and life-threatening injuries have occurred. The following clients arrive from the scene by private vehicle. Which client is considered a priority for treatment? a. Child with an open fracture of the arm b. Man with a contusion on the head c. Teenager with a closed fracture of the leg d. Woman bleeding heavily

d Woman bleeding heavily The woman critically injured with trauma or an active hemorrhage is prioritized as emergent. The emergent triage category implies that a condition exists that poses an immediate threat to life or limb and should be treated immediately. Although the child with an open fracture of the arm, the man with a contusion of the head, and the teenager with a closed fracture of the leg are urgent, they are not emergent and can wait for a short time.

22. Which are modifiable risk factors for type 2 DM? (Select all that apply.) a. Age b. Family history c. Working in a low-stress environment d. Maintaining ideal body weight e. Maintaining adequate physical activity

d, e

11. A deficiency of which anterior pituitary hormones is considered life-threatening? (Select all that apply.) a. GH b. Melanocyte-stimulating hormone (MSH) c. PRL d. Thyroid-stimulating hormone (TSH) e. ACTH

Final

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