MS Test 3
A patient has been newly diagnosed with type 2 diabetes. Which information about the patient will be most useful to the nurse who is helping the patient develop strategies for successful adaptation to this disease?
Value system
Which question from the nurse would help determine if a patient's abdominal pain might
"How long have you had abdominal pain?"
Which information will the nurse include when teaching a patient with peptic ulcer disease about the effect of ranitidine (Zantac)?
"Ranitidine decreases gastric acid secretion."
Which statement by a patient with chronic atrophic gastritis indicates that the nurse's teaching regarding cobalamin injections has been effective?
"The cobalamin injections will prevent me from becoming anemic."
Which patient statement indicates that the nurse's postoperative teaching after a gastroduodenostomy has been effective?
"Vitamin supplements may prevent anemia."
Which question will the nurse in the endocrine clinic ask to help determine a patient's risk factors for goiter?
"What medications are you taking?"
A patient receives aspart (NovoLog) insulin at 8:00 AM. At which time would the nurse anticipate the highest risk for hypoglycemia?
10:00 AM
A patient with a new ileostomy asks how much it will drain. How many cups of drainage per day should the nurse explain for the patient to expect?
2
After change-of-shift report, which patient will the nurse assess first?
A 60-yr-old patient with hyperosmolar hyperglycemic syndrome who has poor skin turgor and dry oral mucosa
After change-of-shift report, which patient should the nurse assess first?
A 60-yr-old patient with nausea and vomiting who is lethargic with dry mucosa
A patient has just arrived in the postanesthesia recovery unit (PACU) after a thyroidectomy. Which information about the patient is most important to communicate to the surgeon?
Increasing neck swelling.
After receiving a change of shift report about the following four patients, which patient should the nurse assess first?
A 70-year-old female patient taking levothyroxine (Synthroid) who has an irregular pulse of 134
A patient with diabetes rides a bicycle to and from work every day. Which site should the nurse teach the patient to use to administer the morning insulin?
Abdomen
What is a likely finding in the nurse's assessment of a patient who has a large bowel obstruction?
Abdominal distention
A patient with acute pancreatitis is NPO and has a nasogastric (NG) tube to suction. Which information obtained by the nurse indicates that these therapies have been effective?
Abdominal pain is decreased.
Which prescribed action will the nurse implement first for a patient who has vomited 1100 mL of blood?
Administer 1 L of lactated Ringer's solution.
A 53-yr-old male patient with deep partial-thickness burns from a chemical spill in the workplace has severe pain followed by nausea during dressing changes. Which action will be most useful in decreasing the patient's nausea?
Administer prescribed morphine sulfate before dressing changes.
When a patient with type 2 diabetes is admitted for a cholecystectomy, which nursing action can the nurse delegate to a licensed practical/vocational nurse (LPN/VN)?
Administer the prescribed lispro (Humalog) insulin before transporting the patient to surgery.
What risk factor will the nurse specifically ask about when a patient is being admitted with acute pancreatitis?
Alcohol use
A patient with a possible pituitary adenoma is scheduled for a computed tomography (CT) scan with contrast media. Which patient information is important for the nurse to communicate to the health care provider before the test?
Allergies to iodine and shellfish
A patient has peptic ulcer disease that has been associated with Helicobacter pylori. About which medications will the nurse plan to teach the patient?
Amoxicillin (Amoxil), clarithromycin (Biaxin), and omeprazole (Prilosec)
A patient who underwent a gastroduodenostomy (Billroth I) 12 hours ago reports increasing abdominal pain. The patient has no bowel sounds and 200 mL of bright red nasogastric (NG) drainage in the past hour. What is the highest priority action by the nurse?
Contact the surgeon.
Which breakfast choice indicates a patient's good understanding of information about a diet for celiac disease?
Corn tortilla with scrambled eggs
The health care provider prescribes antacids and sucralfate (Carafate) for treatment of a patient's peptic ulcer. What should the nurse teach the patient to take?
Antacids after meals and sucralfate 30 minutes before meals
A young adult contracts hepatitis from contaminated food. What should the nurse expect serologic testing to reveal during the acute (icteric) phase of the patient's illness?
Anti-hepatitis A virus immunoglobulin M (anti-HAV IgM)
A patient seen in the emergency department for severe headache and acute confusion has a serum sodium level of 118 mEq/L. The nurse should anticipate the need for which diagnostic test?
Antidiuretic hormone level
An active 32-yr-old male who has type 1 diabetes is being seen in the endocrine clinic. Which finding indicates a need for the nurse to discuss a possible a change in therapy with the health care provider?
Blood pressure of 140/88 mmHg
A 72-yr-old male patient with dehydration caused by an exacerbation of ulcerative colitis is receiving 5% dextrose in normal saline at 125 mL/hour. Which assessment finding by the nurse is most important to report to the health care provider?
Crackles are heard halfway up the posterior chest.
The nurse is assessing a patient with abdominal pain. How will the nurse document ecchymosis around the area of umbilicus?
Cullen sign
Which nursing action is most important in assisting an older patient who has diabetes to engage in moderate daily exercise?
Determine what types of activities the patient enjoys.
An 82-year-old patient in a long-term care facility is newly diagnosed with hypothyroidism. The nurse will need to consult with the health care provider before administering the prescribed
Diazepam (Valium)
A patient being admitted with an acute exacerbation of ulcerative colitis reports crampy abdominal pain and passing 15 bloody stools a day. What should the nurse include in the plan of care?
Discontinue the patient's oral food intake.
Which item should the nurse offer to the patient restarting oral intake after being NPO due to nausea and vomiting?
Dish of lemon gelatin
A patient is transferred from the recovery room to a surgical unit after a transverse colostomy. The nurse observes the stoma to be deep pink with edema and a small amount of sanguineous drainage. What action should the nurse take?
Document stoma assessment findings.
During the physical examination, the nurse cannot feel the patient's thyroid gland. What action should the nurse take?
Document that the thyroid was nonpalpable.
Which activity in the care of a patient with a new colostomy could the nurse delegate to unlicensed assistive personnel (UAP)?
Drain and measure the output from the ostomy.
Which nursing action should be included in the postoperative plan of care for a patient after a laparoscopic esophagectomy?
Elevate the head of the bed to at least 30 degrees.
Which nursing action will be included in the plan of care for a patient with Graves' disease who has exophthalmos?
Elevate the head of the patient's bed to reduce periorbital fluid.
A patient is taking spironolactone (Aldactone), a drug that blocks the action of aldosterone on the kidney, for hypertension. What additional effect of the medication should the nurse monitor?
Elevated serum potassium
A patient reports gas pain and abdominal distention 2 days after a small bowel resection. Which nursing action should the nurse take?
Encourage the patient to ambulate
What diagnostic test should the nurse anticipate for an older patient who is vomiting "coffee-ground" emesis?
Endoscopy
A patient with Crohn's disease who is taking infliximab (Remicade) calls the nurse in the outpatient clinic about new symptoms. Which symptom is most important to communicate to the health care provider?
Fever
A young woman with Crohn's disease develops a fever and symptoms of a urinary tract infection (UTI) with tan, fecal-smelling urine. What information will the nurse add to a general teaching plan about UTIs in order to individualize the teaching for this patient?
Fistulas can form between the bowel and bladder.
The nurse has administered 4 oz of orange juice to an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next?
Give the patient 4 to 6 oz more orange juice.
Which action should the nurse take after a patient treated with intramuscular glucagon for hypoglycemia regains consciousness?
Give the patient a snack of peanut butter and crackers.
A few weeks after an 82-yr-old patient with a new diagnosis of type 2 diabetes has been placed on metformin (Glucophage) therapy, the home health nurse makes a visit. Which finding should the nurse promptly discuss with the health care provider?
Glomerular filtration rate is decreased.
What information will a review of a patient's glycosylated hemoglobin (A1C) results provide to the nurse?
Glucose control over the past 90 days
Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide?
Glyburide stimulates insulin production and release from the pancreas.
A patient with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient?
Glycosylated hemoglobin
The nurse is caring for a patient with a possible pituitary tumor who is scheduled for a computed tomography scan with contrast. Which information about the patient is important to discuss with the health care provider before the test?
History of renal insufficiency
A young adult patient who is being seen in the clinic has excessive secretion of the anterior pituitary hormones. Which laboratory test result should the nurse expect?
Increased urinary cortisol
A patient is admitted to the emergency department with severe abdominal pain and rebound tenderness. Vital signs include temperature 102° F (38.3° C), pulse 120 beats/min, respirations 32 breaths/min, and blood pressure (BP) 82/54 mm Hg. Which prescribed intervention should the nurse implement first?
Infuse a liter of lactated Ringer's solution over 30 minutes.
A patient in the emergency department has just been diagnosed with peritonitis from a ruptured diverticulum. Which prescribed intervention will the nurse implement first?
Infuse metronidazole (Flagyl) 500 mg IV.
A 49-yr-old man has been admitted with hypotension and dehydration after 3 days of nausea and vomiting. Which prescribed action will the nurse implement first?
Infuse normal saline at 250 mL/hr.
An unresponsive patient who has type 2 diabetes is brought to the emergency department and diagnosed with hyperosmolar hyperglycemia syndrome (HHS). What should the nurse anticipate doing?
Inserting an IV catheter
A patient is admitted with tetany. Which laboratory value should the nurse plan to monitor?
Ionized calcium
The nurse administering -interferon and ribavirin (Rebetol) to a patient with chronic hepatitis C will plan to monitor for:
Leukopenia
At his first postoperative checkup appointment after a gastrojejunostomy (Billroth II), a patient reports that dizziness, weakness, and palpitations occur about 20 minutes after each meal. What should the nurse teach the patient to do?
Lie down for about 30 minutes after eating.
A patient who takes a nonsteroidal antiinflammatory drug (NSAID) daily for the management of severe rheumatoid arthritis has recently developed melena. What should the nurse anticipate teaching the patient?
Misoprostol (Cytotec) to protect the gastrointestinal (GI) mucosa
A 26-yr-old female who has type 1 diabetes develops a sore throat and runny nose after caring for her sick toddler. The patient calls the clinic for advice about her symptoms and reports a blood glucose level of 210 mg/dL despite taking her usual glargine (Lantus) and lispro (Humalog) insulin. What should the nurse advise the patient to do?
Monitor blood glucose every 4 hours and contact the clinic if it rises.
Which nursing action will the nurse include in the plan of care for a patient admitted with an exacerbation of inflammatory bowel disease (IBD)?
Monitor stools for blood.
Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient who has acute pancreatitis?
Muscle twitching and finger numbness
Which finding by the nurse when assessing a patient with Hashimoto's thyroiditis and a goiter will require the most immediate action?
New-onset changes in the patient's voice
Which laboratory value reported by the unlicensed assistive personnel (UAP) indicates an urgent need for the nurse to assess the patient?
Noon blood glucose of 52 mg/dL
A 36-yr-old female patient is receiving treatment for chronic hepatitis B with pegylated interferon (Pegasys). Which finding is important to communicate to the health care provider to suggest a change in therapy?
Positive urine pregnancy test
Which prescribed medication should the nurse expect will have rapid effects on a patient admitted to the emergency department in thyroid storm?
Propranolol (Inderal)
What should the nurse anticipate teaching a patient with a new report of heartburn?
Proton pump inhibitors
A young adult patient is admitted to the hospital for evaluation of right lower quadrant abdominal pain with nausea and vomiting. Which action should the nurse take?
Suggest the patient lie on the side, flexing the right leg.
A patient who has hyperthyroidism is treated with radioactive iodine (RAI). What information should the nurse include in discharge teaching?
Symptoms of hypothyroidism will occur as the RAI therapy takes effect.
Which assessment should the nurse perform first for a patient who just vomited bright red blood?
Taking the blood pressure (BP) and pulse
The nurse is assessing a patient who had a total gastrectomy 8 hours ago. What information is most important to report to the health care provider?
Temperature 102.1° F (38.9° C)
Which assessment finding for an adult admitted with Graves' disease requires the most rapid intervention by the nurse?
Temperature 103.8° F (40.4° C)
The nurse and a licensed practical/vocational nurse (LPN/VN) are working together to care for a patient who had an esophagectomy 2 days ago. Which action by the LPN/VN requires that the nurse intervene?
The LPN/VN positions the head of the bed in the flat position.
A registered nurse (RN) is caring for a patient with a goiter and possible hyperthyroidism. Which action by the RN indicates that the charge nurse needs to provide the RN with additional teaching?
The RN palpates the neck to assess thyroid size.
Which response by the nurse best explains the purpose of ranitidine (Zantac) for a patient who was admitted with bleeding esophageal varices?
The medication will prevent irritation of the enlarged veins.
A patient who has type 2 diabetes is being prepared for an elective coronary angiogram. Which information would the nurse anticipate might lead to rescheduling the test?
The patient took the prescribed metformin today.
Which information from a 70-yr-old patient during a health history indicates to the nurse that the patient should be screened for hepatitis C?
The patient used IV drugs about 20 years ago.
A female patient is scheduled for an oral glucose tolerance test. Which information from the patient's health history is important for the nurse to communicate to the health care provider regarding this test?
The patient uses oral contraceptives.
The nurse is assessing a 55-yr-old female patient with type 2 diabetes who has a body mass index (BMI) of 31 kg/m2.Which goal in the plan of care is most important for this patient?
The patient will reach a glycosylated hemoglobin level of less than 7%.
Which finding indicates a need to contact the health care provider before the nurse administers metformin (Glucophage)?
The patient's estimated glomerular filtration rate is 42 mL/min.
The nurse is administering IV fluid boluses and nasogastric irrigation to a patient with acute gastrointestinal (GI) bleeding. Which assessment finding is most important for the nurse to communicate to the health care provider?
The patient's lungs have crackles audible to the midchest.
Which assessment information will be most important for the nurse to report to the health care provider about a patient who has acute cholecystitis?
The patient's stools are tan colored.
Which additional information should the nurse consider when reviewing the laboratory results for a patient's total calcium level?
The serum albumin
The nurse is providing preoperative teaching for a patient scheduled for an abdominal-perineal resection. Which information will the nurse include?
The site where the stoma will be located will be marked on the abdomen preoperatively.
A 33-yr-old male patient with a gunshot wound to the abdomen undergoes surgery, and a colostomy is formed as shown in the accompanying figure. Which information will be included in patient teaching?
This type of colostomy is usually temporary.
Which laboratory value should the nurse review to determine whether a patient's hypothyroidism is caused by a problem with the anterior pituitary gland?
Thyroid-stimulating hormone (TSH) level
Which information will the nurse include in teaching a patient who had a proctocolectomy and ileostomy for ulcerative colitis?
Use care when eating high-fiber foods to avoid obstruction of the ileum.
The nurse evaluates that administration of hepatitis B vaccine to a healthy patient has been effective when the patient's blood specimen reveals:
anti-HBs.
A patient had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to:
urn, cough, and deep breathe every 2 hours.
Which statement by the patient who has newly diagnosed type 1 diabetes indicates a need for additional instruction from the nurse?
"I can choose any foods, as long as I use enough insulin to cover the calories."
Which information about dietary management should the nurse include when teaching a patient with peptic ulcer disease (PUD)?
"Avoid foods that cause pain after you eat them."
A patient who has gastroesophageal reflux disease (GERD) is experiencing increasing discomfort. Which patient statement to the nurse indicates that additional teaching about GERD is needed?
"I eat small meals and have a bedtime snack."
Which patient statement to the nurse indicates a need for additional instruction in administering insulin?
"I need to rotate injection sites among my arms, legs, and abdomen each day."
Which patient statement indicates that the nurse's teaching about sulfasalazine (Azulfidine) for ulcerative colitis has been effective?
"I should apply sunscreen before going outdoors."
A 26-yr-old woman is being evaluated for vomiting and abdominal pain. Which question from the nurse will be most useful in determining the cause of the patient's symptoms?
"Can you tell me more about the pain?"
A patient is scheduled in the outpatient clinic for blood cortisol testing. Which instruction should the nurse provide?
"Come to the laboratory to have the blood drawn early in the morning."
Which question during the assessment of a patient who has diabetes will help the nurse identify autonomic neuropathy?
"Do you feel bloated after eating?"
A patient admitted with an abrupt onset of jaundice and nausea has abnormal liver function studies, but serologic testing is negative for viral causes of hepatitis. Which question by the nurse is appropriate?
"Do you use any over-the-counter drugs?"
Which question from the nurse during a patient interview will provide focused information about a possible thyroid disorder?
"Have you had a recent unplanned weight gain or loss?"
The nurse is assessing a 22-yr-old patient experiencing the onset of symptoms of type 1 diabetes. To which question would the nurse anticipate a positive response?
"Have you lost weight lately?"
The nurse is admitting a 67-yr-old patient with new-onset steatorrhea. Which question is most important for the nurse to ask?
"Have you noticed a recent weight loss?"
A 58-yr-old woman who was recently diagnosed with esophageal cancer tells the nurse, "I do not feel ready to die yet." Which response by the nurse is most appropriate?
"Having this new diagnosis must be very hard for you."
A young adult patient is hospitalized with massive abdominal trauma from a motor vehicle crash. The patient asks the nurse about the purpose of receiving famotidine (Pepcid). What should the nurse explain about the action of the medication?
"It inhibits development of stress ulcers."
How should the nurse explain esomeprazole (Nexium) to a patient with recurring heartburn?
"It treats gastroesophageal reflux disease by decreasing stomach acid production."
Which information will the nurse provide for a patient with newly diagnosed gastroesophageal reflux disease (GERD)?
"Keep the head of your bed elevated on blocks."
The nurse has been teaching a patient with type 2 diabetes about managing blood glucose levels and taking glipizide (Glucotrol). Which patient statement indicates a need for additional teaching?
"My diabetes won't cause complications because I don't need insulin."
Which information will the nurse include when teaching a patient how to avoid chronic constipation? (Select all that apply.)
Bulk-forming laxatives are an excellent source of fiber, Walking or cycling frequently will help bowel motility, A good time for a bowel movement may be after breakfast, Some over-the-counter (OTC) medications cause constipation.
After a change-of-shift report, which patient should the nurse assess first?
A 23-yr-old patient with type 1 diabetes who has a blood glucose of 40 mg/dL
In preparation for which test should the nurse teach the patient to minimize physical and emotional stress?
A 24-hour urine test for free cortisol
Which patient should the nurse assess first after receiving a change-of-shift report?
A 30-yr-old patient who has a distended abdomen and tachycardia
After having frequent diarrhea and a weight loss of 10 lb (4.5 kg) over 2 months, a patient has a new diagnosis of Crohn's disease. What should the nurse plan to teach the patient?
Medication use
An 80-yr-old patient who is hospitalized with peptic ulcer disease develops new-onset auditory hallucinations. Which prescribed medication will the nurse discuss with the health care provider before administration?
Metoclopramide (Reglan)
A young adult has been admitted to the emergency department with nausea and vomiting. Which action could the RN delegate to unlicensed assistive personnel (UAP)?
Assist the patient with oral care.
Which information will the nurse teach a patient who has been newly diagnosed with Graves' disease?
Antithyroid medications may take several months for full effect.
A 30-yr-old patient has a new diagnosis of type 2 diabetes. When should the nurse recommend the patient schedule a dilated eye examination?
As soon as available
A 25-yr-old male patient calls the clinic reporting diarrhea for 24 hours. Which action should the nurse take first?
Ask the patient to describe the stools and any associated symptoms.
To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually? (Select all that apply.)
Blood pressure, Serum creatinine, Urine for microalbuminuria, Monofilament testing of the foot
A 68-yr-old male patient with a stroke is unconscious and unresponsive to stimuli. After learning that the patient has a history of gastroesophageal reflux disease (GERD), what should the nurse plan to assess more frequently than is routine?
Breath sounds
Which care activity for a patient with a paralytic ileus is appropriate for the registered nurse (RN) to delegate to unlicensed assistive personnel (UAP)?
Brushing the teeth and tongue
Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is accurate?
Changes in diet and exercise may control blood glucose levels in type 2 diabetes.
Which action should the nurse in the emergency department take first for a new patient who is vomiting blood?
Check blood pressure and heart rate.
Four hours after a bowel resection, a 74-yr-old male patient with a nasogastric tube to suction reports nausea and abdominal distention. What should be the nurse's first action?
Check for tube placement and reposition it.
A patient who has type 1 diabetes plans to swim laps for an hour daily at 1:00 PM. What advice should the clinic nurse plan to give the patient?
Check glucose level before, during, and after swimming.
The health care provider suspects the Somogyi effect in a 50-yr-old patient whose 6:00 AM blood glucose is 230 mg/dL. Which action will the nurse teach the patient to take?
Check the blood glucose during the night.
When taking the blood pressure (BP) on the right arm of a patient who has severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next?
Check the calcium level in the chart.
What should the nurse plan to teach about to a patient with Crohn's disease who has megaloblastic anemia?
Cobalamin (B12) supplements
A patient calls the clinic to report a new onset of severe diarrhea. What should the nurse anticipate that the patient will need to do?
Collect a stool specimen
What should the nurse preparing for the annual physical exam of a 45-yr-old man plan to teach the patient about?
Colonoscopy
What topic should the nurse plan to teach the patient diagnosed with acute hepatitis B?
Measures for improving appetite
Which finding indicates to the nurse that the current therapies are effective for a patient who has acute adrenal insufficiency?
Increasing serum sodium levels
A patient with diabetic ketoacidosis is brought to the emergency department. Which prescribed action should the nurse implement first?
Infuse 1 L of normal saline per hour.
Which information will the nurse plan to teach a patient who has lactose intolerance?
Live-culture yogurt is usually tolerated.
Which goal has the highest priority in the plan of care for a 26-yr-old patient who was admitted with viral hepatitis, has severe anorexia and fatigue, and is homeless?
Maintain adequate nutrition.
The nurse is planning care for a patient with acute severe pancreatitis. What is the highest priority patient outcome?
Maintaining normal respiratory function
What should the nurse teach a patient with chronic pancreatitis is the time to take the prescribed pancrelipase (Viokase)?
Mealtime
A patient with chronic hepatitis B infection has several medications prescribed. Which medication order requires clarification with the health care provider before administration?
Pegylated -interferon (Pegasys) orally once daily
A 27-yr-old patient admitted with diabetic ketoacidosis (DKA) has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first?
Place the patient on a cardiac monitor.
After several days of antibiotic therapy for pneumonia, an older hospitalized patient develops watery diarrhea. Which action should the nurse take first?
Place the patient on contact precautions.
A patient is awaiting surgery for acute peritonitis. Which action will the nurse plan to include in the preoperative care?
Position patient with the knees flexed.
Which patient action indicates accurate understanding of the nurse's teaching about administration of aspart (NovoLog) insulin?
The patient cleans the skin with soap and water before insulin administration.
Which action by a patient indicates that the home health nurse's teaching about glargine and regular insulin has been successful?
The patient discards the open vials of glargine and regular insulin after 4 weeks.
The nurse is interviewing a new patient with diabetes who takes rosiglitazone (Avandia). Which information would the nurse anticipate resulting in the health care provider discontinuing the medication?
The patient has chest pressure when walking.
Which information obtained by the nurse interviewing a 30-yr-old male patient is most important to communicate to the health care provider?
The patient has noticed blood in the stools.
A 28-yr-old male patient with type 1 diabetes reports how he manages his exercise and glucose control. Which behavior indicates that the nurse should implement additional teaching?
The patient increases daily exercise when ketones are present in the urine.
Which diet choice by the patient with an acute exacerbation of inflammatory bowel disease (IBD) indicates a need for more teaching?
Oatmeal with cream
The nurse recognizes that teaching a patient following a laparoscopic cholecystectomy has been effective when the patient makes which statement?
"I can take a shower and walk around the house tomorrow."
Which statement made by a 50-yr-old female patient indicates to the nurse that further assessment of thyroid function may be needed?
"I feel a lump in my throat when I swallow."
A patient in the outpatient clinic is diagnosed with acute hepatitis C (HCV) infection. Which action by the nurse is appropriate?
Schedule the patient for HCV genotype testing.
A patient has just been admitted to the emergency department with nausea and vomiting. Which information requires the most rapid intervention by the nurse?
The patient is lethargic and difficult to arouse.
A patient admitted with a peptic ulcer has a nasogastric (NG) tube in place. When the patient develops sudden, severe upper abdominal pain, diaphoresis, and a firm abdomen, which action should the nurse take?
Check the vital signs.
Which patient choice for a snack 3 hours before bedtime indicates that the nurse's teaching about gastroesophageal reflux disease (GERD) has been effective?
Cherry gelatin with fruit
A 44-year-old female patient with Cushing syndrome is admitted for adrenalectomy. Which intervention by the nurse will be helpful for the patient problem of disturbed body image related to changes in appearance?
Remind the patient that most of the physical changes caused by Cushing syndrome will resolve after surgery.
A hospitalized patient who is diabetic received 38 U of NPH insulin at 7:00 AM. At 1:00 PM, the patient has been away from the nursing unit for 2 hours, missing the lunch delivery while awaiting a chest x-ray. What is the best action by the nurse to prevent hypoglycemia?
Request that if testing is further delayed, the patient will eat lunch first.
A patient screened for diabetes at a clinic has a fasting plasma glucose level of 120 mg/dL (6.7 mmol/L). What should the nurse plan to teach the patient
Lifestyle changes to lower blood glucose
Which laboratory test result will the nurse monitor to evaluate the effects of therapy for a patient who has acute pancreatitis?
Lipase
A patient with diabetes is starting on intensive insulin therapy. Which type of insulin will the nurse discuss using for mealtime coverage?
Lispro (Humalog)
A patient who was admitted with diabetic ketoacidosis secondary to a urinary tract infection has been weaned off an insulin drip 30 minutes ago. The patient reports feeling lightheaded and sweaty. Which action should the nurse take first?
Obtain a glucose reading using a finger stick.
Which action should the nurse in the emergency department anticipate for a young adult patient who has had several acute episodes of bloody diarrhea?
Obtain a stool specimen for culture.
Which assessment finding is of most concern for a patient with acute pancreatitis?
Palpable abdominal mass
A patient who was admitted with myxedema coma and diagnosed with hypothyroidism is improving. Discharge is expected to occur in 2 days. Which teaching strategy is likely to result in effective patient self-management at home?
Provide written reminders of information taught.
For a patient who has cirrhosis, which nursing action can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)?
Providing oral hygiene after a meal
A patient is being admitted with a diagnosis of Cushing syndrome. Which finding will the nurse expect during the assessment?
Purplish streaks on the abdomen
The nurse is taking a health history from a 29-yr-old patient at the first prenatal visit. The patient reports that she has no personal history of diabetes, but her mother has diabetes. Which action will the nurse plan to take?
Schedule the patient for a fasting blood glucose level.
A 19-yr-old patient has FAP. Which action will the nurse in the gastrointestinal clinic include in the plan of care?
Schedule the patient for yearly colonoscopy.
A patient born in 1955 had hepatitis A infection 1 year ago. According to Centers for Disease Control and Prevention (CDC) guidelines, which action should the nurse include in care when the patient is seen for a routine annual physical examination?
Ask whether the patient has been screened for hepatitis C.
The nurse is preparing to teach a 43-yr-old man who is newly diagnosed with type 2 diabetes about home management of the disease. Which action should the nurse take first?
Assess the patient's perception of what it means to have diabetes.
A patient had an abdominal-perineal resection for colon cancer. Which nursing action is most important to include in the plan of care for the day after surgery?
Assess the perineal drainage and incision.
Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs?
Choose flat-soled leather shoes.
Which action by the patient who is self-monitoring blood glucose indicates a need for additional teaching?
Chooses a puncture site in the center of the finger pad.
A 76-yr-old patient with obstipation has a fecal impaction and is incontinent of liquid stool. Which action should the nurse take first?
Manually remove the impacted stool.
Which action will the nurse include in the plan of care for a patient who has been diagnosed with chronic hepatitis B?
Schedule for liver cancer screening every 6 months.
When a patient who takes metformin (Glucophage) to manage type 2 diabetes develops an allergic rash from an unknown cause, the health care provider prescribes prednisone. What should the nurse anticipate?
The patient may require administration of insulin while taking prednisone.
Which patient action indicates an accurate understanding of the nurse's teaching about the use of an insulin pump?
The patient programs the pump for an insulin bolus after eating.
Which information about a patient who is scheduled for an oral glucose tolerance test should the nurse consider in interpreting the test results?
The patient takes oral corticosteroids for rheumatoid arthritis.
A patient vomiting blood-streaked fluid is admitted to the hospital with acute gastritis. What should the nurse ask the patient about to determine possible risk factors for gastritis?
Use of nonsteroidal antiinflammatory drugs
