Saunders NCLEX Questions

After several diagnostic tests, a client is diagnosed with DI. A nurse performs an assessment on the client, knowing that which symptom is most indicative of this disorder? a. Fatigue b. Diarrhea c. Polydipsia d. Weight gain

c. Polydipsia Rationale: polydipsia and polyuria are classic symptoms of DI. The urine is pale, and the specific gravity is low. Anorexia and weight loss occur. Option 1 is a vague symptom. Options 2 and 4 are not specific to this disorder.

A nurse is providing discharge instructions to a client who has Cushing's syndrome. Which client statement indicates that instructions related to dietary management are understood? a. "I can eat foods that have a lot of potassium in them." b. "I will need to limit the amount of protein in my diet." c. "I am fortunate that I can eat all the salty foods I enjoy." d. "I am fortunate that I do not need to follow any special diet."

a. "I can eat foods that have a lot of potassium in them." Rationale: a diet low in carbs and sodium but ample in protein and potassium is encouraged for a client with Cushing's syndrome. Such a diet promotes weight loss, reduction of edema and hypertension, control of hypokalemia, and rebuilding of wasted tissue.

A home health nurse visits a client with a diagnosis of type 1 DM. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for 36 hours. Which additional statement by the client indicates a need for further teaching? a. "I need to stop my insulin." b. "I need to increase my fluid intake." c. "I need to monitor my blood glucose every 3 to 4 hours." d. "I need to call the physician because of these symptoms."

a. "I need to stop my insulin." Rationale: when a client with DM is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the physician. The client should monitor the blood glucose level every 3 to 4 hours.

A nurse is preparing a plan of care for a client with DM who has hyperglycemia. The priority nursing diagnosis would be: a. Fluid volume, deficient b. Family processes, dysfunctional c. Nutrition: less than body requirements, imbalanced d. Knowledge, deficient: disease process and treatment

a. Fluid volume, deficient Rationale: an increased blood glucose level will cause the kidneys to excrete the glucose in the urine. This glucose is accompanied by fluids and electrolytes, causing an osmotic diuresis leading to dehydration. This fluid loss must be replaced when it becomes severe. Options 2, 3, and 4 are not related specifically to the subject of the question.

The client is brought to the emergency room and is experiencing an anaphylactic reaction from eating shellfish. The nurse implements which immediate action? a. Maintaining a patent airway b. Administering a corticosteroid c. Administering epinephrine d. Instructing the client on the important of obtaining a Medic-Alert bracelet

a. Maintaining a patent airway Rationale: If the client experiences an anaphylactic reaction, the immediate action would be to maintain a patent airway. The client then would receive epinephrine. Corticosteroids also may be prescribed. The client will need to be instructed about obtaining and wearing a Medic-Alert bracelet, but this is not the immediate action.

A nurse is monitoring the client newly diagnosed with DM for signs of complications. Which of the following, if exhibited in the client, would indicate hyperglycemia and warrant physician notification? a. Polyuria b. Diaphoresis c. Hypertension d. Increased pulse rate

a. Polyuria Rationale: classic symptoms of hyperglycemia include polydipsia, polyuria, and polyphagia. Options 2, 3, and 4 are not signs of hyperglycemia.

A nurse notes that a client with type 1 DM has lipodystrophy on both upper thighs. The nurse would appropriately inquire whether the client: a. Rotates sites for injection b. Administers the insulin at a 45-degree angle c. Cleanses the skin with alcohol before each injection d. Aspirates for blood before injection into the subcutaneous tissue

a. Rotates sites for injection Rationale: lipodystrophy (hypertrophy of subcutaneous tissue at the injection site) occurs in some clients with DM when injection sites are used for a prolonged period of time. Thus, clients are instructed to adhere to a plan of rotating injection sites to avoid tissue changes. Cleansing with alcohol, aspiration, and angle of insulin administration do not produce this complication.

A nurse is caring for a client with type 1 DM. Which client complaint would alert the nurse to the presence of a possible hypoglycemic reaction? a. Tremors b. Anorexia c. Hot, dry skin d. Muscle cramps

a. Tremors Rationale: decreased blood glucose levels produce autonomic nervous system symptoms, which are manifested classically as nervousness, irritability, and tremors. Option 3 is more likely to occur with hyperglycemia. Options 2 and 4 are unrelated to the signs of hypoglycemia.

The family of a bedridden client with type 2 DM and chronic renal failure calls a nurse to report the following symptoms: headache, polydipsia, and increased lethargy. To determine a possible diagnosis, the nurse asks the family which most important question? a. "What is the client's urine output?" b. "What is the client's capillary blood glucose level?" c. "Has there been any change in the dietary intake?" d. "Have you increased the amount of fluids provided?"

b. "What is the client's capillary blood glucose level?" Rationale: HHNS is in acute complication of type 2 diabetes, leading to hyperglycemia and dehydration. Headache and polydipsia an increasing lethargy can be caused by the dehydration. Options 1, 3 and 4 will not assist in determining a possible diagnosis.

A client calls the nurse in the emergency room and tells the nurse that he was just stung by a bumble bee while gardening. The client is afraid of a severe reaction because the client's neighbor just experienced such a reaction just 1 week ago. The appropriate nursing action is to: a. Advise the client to soak the site in hydrogen peroxide b. Ask the client if he ever sustained a bee sting in the past c. Tell the client to call an ambulance for transport to the emergency room d. Tell the client not to worry about the sting unless difficulty with breathing occurs

b. Ask the client if he ever sustained a bee sting in the past Rationale: in some types of allergies, a reaction occurs only on a second and subsequent contacts with the allergen. The appropriate action, therefore, would be to ask the client if he ever received a bee sting in the past. Option 1 is not appropriate advice. Option 3 is unnecessary. The client should not be told "not to worry."

A client with DM demonstrates acute anxiety when first admitted for the treatment of hyperglycemia. The appropriate intervention to decrease the client's anxiety is to: a. Administer a sedative b. Convey empathy, trust, and respect towards the client c. Ignore the signs and symptoms of anxiety so that they will disappear soon d. Make sure that the client knows all the correct medical terms to understand what is happening

b. Convey empathy, trust, and respect towards the client Rationale: the appropriate intervention is to address the client's feelings related to the anxiety. Administering a sedative is not the most appropriate intervention. The nurse should not ignore the clients anxious feelings. A client will not relate to medical terms, particularly when anxiety exists.

The nurse is caring for a client who is 2 days post-operative following an abdominal hysterectomy. The client has a history of DM and has been receiving regular insulin according to capillary blood glucose testing four times a day. A carbohydrate controlled diet has been prescribed but the client has been complaining of nausha and is not eating. On entering the clients room, the nurse finds the client to be confused and diaphoretic. Which action is appropriate at this time? a. Call a code to obtain needed assistance immediately b. Obtain a capillary blood glucose level and perform a focused assessment c. Stay with the client and ask the nursing assistant to call the physician for an order of intravenous 50% dextrose d. Ask the nursing assistant to stay with the client while obtaining 15 to 30 grams of a carbohydrate snack for the client to eat

b. Obtain a capillary blood glucose level and perform a focused assessment Rationale: diaphoresis and confusion are signs of moderate hypoglycemia. A likely cause of the clients changing condition could be related to the administration of insulin without the client eating enough food. However, in assessment is necessary to confirm the presence of hypoglycemia. The nurse would obtain a capillary blood glucose level to confirm the hypoglycemia and perform a focused assessment to determine the extent and cause of the client's condition. Once hypoglycemia is confirmed the nurse stays with the client and asked the nursing assistant to obtain the appropriate carbohydrate snack. A code is called if the client is not breathing or if the heart is not beating.

A nurse teaches a client with a DM about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which of the following symptoms develops? a. Polyuria b. Shakiness c. Blurred vision d. Fruity breath odor

b. Shakiness Rationale: shakiness is a sign of hypoglycemia and would indicate the need for food or glucose. A fruity breath odor, blurred vision, and polyuria are signs of hyperglycemia.

A nurse is caring for a client after hypophysectomy. The nurse notices clear nasal drainage from the client's nostril. The initial nursing action would be to: a. Lower the head of the bed b. Test the drainage for glucose c. Obtain a culture of the drainage d. Continue to observe the drainage

b. Test the drainage for glucose Rationale: after hypophysectomy, the client should be monitored for rhinorrhea, which could indicate a cerebrospinal fluid leak. if this occurs, the drainage should be collected and tested for the presence of CSF. The head of the bed should not be lowered to prevent increased intracranial pressure. Clear nasal drainage would not indicate the need for a culture. Continuing to observe the drainage without taking action could result in a serious complication.

A client with type 1 DM calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an inadequate understanding of the peak action of NPH insulin and exercise? a. "The best time for me to exercise is after I eat." b. "The best time for me to exercise is after breakfast." c. "The best time for me to exercise is mid to late afternoon." d. "The best time for me to exercise is after my morning snack."

c. "The best time for me to exercise is mid to late afternoon." Rationale: a hypoglycemic reaction may occur in response to increased exercise. Clients should avoid exercise during the peak time of insulin. NPH insulin peaks at 4 to 12 hours; therefore, afternoon exercise takes place during the peak of the medication. Options 1, 2, and 4 do not address peak action times.

A nurse is preparing a teaching plan for a client with DM regarding proper foot care. Which instruction is included in the plan? a. Soak feet in hot water b. Avoid using a mild soap on the feet c. Apply a moisturizing lotion to dry feet but not between the toes d. Always have a podiatrist cut your toenails; never cut them yourself

c. Apply a moisturizing lotion to dry feet but not between the toes Rationale: the client is instructed to use a moisturizing lotion on the feet and to avoid applying the lotion between the toes. The client should be instructed not to soak the feet and should avoid hot water to prevent burns. The client may cut the toenail straight across and even with the toe itself and would consult a podiatrist at the toenails were thick or hard to cut or if vision were poor. The client should be instructed to wash the feet daily with a mild soap.

A nurse needs to maintain food and fluid intake to minimize the risk of dehydration in a client with DM who has gastroenteritis. The appropriate nursing intervention is to: a. Offer water only until the client is able to tolerate solid foods b. Withhold all fluids until vomiting has ceased for at least four hours c. Encourage the client to take 8 to 12 ounces of fluid every hour while awake d. Maintain a clear liquid diet for at least five days before advancing to solids to allow inflammation of the stomach and bowel to dissipate

c. Encourage the client to take 8 to 12 ounces of fluid every hour while awake Rationale: small amounts of fluid may be tolerated, even when vomiting is present. The nurse should encourage liquid's containing glucose and electrolytes every hour. Options 1, 2, and 4 will not provide the adequate intake needed by the client with DM.

A client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose level was 950 mg/dL. A continuous intravenous infusion of regular insulin is initiated, along with intravenous rehydration with normal saline. The serum glucose level is now 240 mg/dL. The nurse would next prepare to administer which of the following? a. Ampule of 50% dextrose b. NPH insulin subcutaneously c. Intravenous fluids containing 5% dextrose d. Phenytoin (Dilantin) for the prevention of seizures

c. Intravenous fluids containing 5% dextrose Rationale: during management of DKA, when the blood glucose level falls to 250 to 350 mg/dL, the infusion rate is reduced and 5% dextrose is added to maintain a blood glucose level of about 250 mg/dL, or until the client recovers from ketosis. NPH insulin is not used to treat DKA. 50% dextrose is used to treat hypoglycemia. Phenytoin (Dilantin) is not a usual treatment measure for DKA.

A nurse is caring for a client with OA. The nurse performs an assessment, knowing that which of the following is a clinical manifestation associated with the disorder? a. Morning stiffness b. A decreased sedimentation rate c. Joint paint that diminishes after rest d. Elevated antinuclear antibody levels

c. Joint paint that diminishes after rest The stiffness and joint pain that occur in osteoarthritis diminish after rest and intensify with activity. No specific laboratory findings are useful in diagnosing osteoarthritis. The client may have a normal or slightly elevated sedimentation rate. Morning stiffness lasting longer than 30 minutes occurs in rheumatoid arthritis. Elevated white blood cell counts, platelet counts, an antinuclear antibody levels occur in rheumatoid arthritis.

A nurse is assisting a client with DM who is recovering from DKA to develop a plan to prevent a recurrence. Which of the following is most important to include in the plan of care? a. Test urine for ketone levels b. Eat 6 small meals per day c. Monitor blood glucose levels frequently d. Receive appropriate follow-up care

c. Monitor blood glucose levels frequently Rationale: client education following DKA should emphasize the need for home glucose monitoring 2 to 4 times per day. Instructing the client to notify the HCP when illness occurs is also important. The presence of urine ketones indicates that the DKA has occured already. The client should eat well balanced meals with snacks as prescribed.

A nurse is preparing to provide instructions to a client with Addison's disease regarding diet therapy. The nurse knows that which of the following diets most likely would be prescribed for this client? a. High-fat intake b. Low-protein intake c. Normal sodium intake d. Low-carb intake

c. Normal sodium intake Rationale: a high-complex carb and high-protein diet will be prescribed for the client with Addison's disease. To prevent excess fluid and sodium loss, the client is instructed to maintain a normal salt intake daily (3 g) and to increase salt intake during hot weather, before strenuous exercise, and in response to fever, vomiting, or diarrhea. A high fat diet is not prescribed.

A nurse performs a physical assessment on a client with type 2 DM. Findings include a fasting blood glucose of 120 mg/dL, temperature of 101 degrees Fahrenheit, pulse of 88 beats/min, respirations of 22 breaths/min, and blood pressure of 100/72 mm Hg. which finding would be of most concern to the nurse? a. Pulse b. Respiration c. Temperature d. Blood pressure

c. Temperature Rationale: an elevated temperature may indicate infection. Infection is a leading cause of HHNS or DKA. The other findings noted in the question are within normal limits.

A nursing instructor asks a student to describe the pathophysiology that occurs in cushings disease. Which statement by the student indicates an accurate understanding of this disorder? a. "Cushings disease results from an over secretion of insulin." b. "Cushings disease results from an under secretion of corticotropic hormones." c. "Cushing's disease results from an under secretion of mineralocorticoid hormones." d. "Cushing's disease results from an increased pituitary secretion of adrenocorticotropic hormone."

d. "Cushing's disease results from an increased pituitary secretion of adrenocorticotropic hormone." Rationale: Cushing's disease is a metabolic disorder characterized by abnormally increased secretion (endogenous) of cortisol, caused by increased amounts of adrenocorticotropic hormone (ACTH) secreted by the pituitary gland. Addison's disease is characterized by the hyposecretion of adrenal cortex hormones (glucocorticoids and mineralocorticoids) from the adrenal gland, resulting in deficiency of the corticosteroid hormones. Options 1, 2, and 3 are inaccurate regarding Cushing's disease.

A nurse provides instructions to a client newly diagnosed with type one DM. The nurse recognizes accurate understanding of measures to prevent DKA when the client states: a. "I will stop taking my insulin if I'm too sick to eat." b. "I will decrease my insulin dose during times of illness." c. "I will adjust my insulin dose according to the level of glucose in my urine." d. "I will notify my physician if my blood glucose level is higher than 250 mg/dL."

d. "I will notify my physician if my blood glucose level is higher than 250 mg/dL." Rationale: during illness, the client should monitor blood glucose levels and should notify the physician at the level is higher than 250 mg/dL. Insulin should never be stopped. In fact, insulin may need to be increased during times of illness. Doses should not be adjusted without the physician's advice and are usually adjusted based on blood glucose levels, not urinary glucose readings.

A nurse is interviewing a client with type 2 DM. Which statement by the client indicates an understanding of the treatment for this disorder? a. "I take oral insulin instead of shots." b. "By taking these medications, I am able to eat more." c. "When I become ill, I need to increase the number of pills I take." d. "The medications I'm taking help release the insulin I already make."

d. "The medications I'm taking help release the insulin I already make." Rationale: clients with type 2 DM have decreased or impaired insulin secretion. Oral hypoglycemic agents are given to those clients to facilitate glucose uptake. Insulin injections may be given during times of stress-induced hyperglycemia. Oral insulin is not available because of the breakdown of the insulin by digestion. Options 1, 2, and 3 are incorrect.

A nurse is caring for a client admitted to the emergency room with DKA. In the acute phase the priority nursing action is to prepare to: a. Correct the acidosis b. Apply a monitor for an electrocardiogram c. Administer 5% dextrose intravenously d. Administer regular insulin intravenously

d. Administer regular insulin intravenously Rationale: lack (absolute or relative) of insulin is the primary cause of DKA. Treatment consists of insulin administration (regular insulin), IV fluid administration (normal saline initially), and potassium replacement, followed by correcting acidosis. Applying an electrocardiogram monitor is not a priority action.

After hypophysectomy, a client complaints of being thirsty and having to urinate frequently. The initial nursing action is to: a. Increase fluid intake b. Document the complaints c. Assess for urinary glucose d. Assess urine specific gravity

d. Assess urine specific gravity Rationale: after hypophysectomy, DI can occur temporarily because of antidiuretic hormone deficiency. This deficiency is related to surgical manipulation. The nurse should assess the specific gravity of the urine and notify the physician if the result is lower than 1.006. Although options 1 and 2 may be components of the plan of care, they are not initial actions. Additionally, the physician will prescribe increased fluids. Option 3 is unrelated to the client's condition.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in an emergency room. Which finding would a nurse expect to note as confirming this diagnosis? a. Comatose state b. Decreased urine output c. Increased respirations in an increase in pH d. Elevated blood glucose level an low plasma bicarbonate level

d. Elevated blood glucose level an low plasma bicarbonate level Rationale: in DKA, the arterial pH is lower than 7.35, plasma bicarbonate is a lower than 15 mEq/L, the blood glucose level is higher than 250 mg/dL, and ketones are present in the blood in urine. The client would be experiencing polyuria, and Kussmaul's respirations would be present. A comatose state may occur if DKA is not treated, but coma would not confirm the diagnosis.

In external insulin pump is prescribed for a client with DM in the client ask the nurse about the functioning of the pump. The nurse bases the response on the information that the pump: a. Is timed to release programmed doses of regular or NPH insulin into the bloodstream at specific intervals b. Continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels c. Is surgically attached to the pancreas and infuses regular insulin into the pancreas which in turn releases the insulin into the bloodstream d. Gives a small continuous dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal

d. Gives a small continuous dose of regular insulin subcutaneously, and the client can self-administer a bolus with an additional dose from the pump before each meal Rationale: an insulin pump provides a small continuous dose of regular insulin subcutaneously throughout the day and night, and the client can self-administer a bolus with an additional dose from the pump before each meal as needed. Regular insulin is used in an insulin pump. An external pump is not attached surgically to the pancreas.

A client with type 2 DM has a blood glucose level higher than 600 mg/dL and is complaining of polydipsia, polyuria, weight loss, and weakness. A nurse reviews the physician's documentation and would expect to note which of the following diagnoses? a. Hypoglycemia b. Pheochromocytoma c. DKA d. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS)

d. Hyperglycemic hyperosmolar nonketotic syndrome (HHNS) Rationale: HHNS occurs in clients with type 2 DM. The onset of symptoms may be gradual. These symptoms may include polyuria, polydipsia, dehydration, mental status alterations, weight loss, and weakness. Options 1, 2, and 3 are incorrect interpretations of the client symptoms.

The evening nurse reviews the nursing documentation in the client's chart and notes that the day nurse has documented that the client has a stage 2 pressure ulcer in the sacral area. Which of the following would the nurse expect to note on assessment of the client's sacral area? a. Intact skin b. Full-thickness skin loss c. Exposed bone, tendon, or muscle d. Partial-thickness skin loss of the dermis

d. Partial-thickness skin loss of the dermis Rationale: in a stage II pressure ulcer, the skin is not intact. Partial-thickness skin loss of the dermis has occurred. It presents as a shallow-open ulcer with a red-pink wound bed, without slough. It may also present as an intact, open or ruptured, serum-filled blister. The skin is intact in stage I. Full-thickness skin loss occurs in stage III. Exposed bone, tendon, or muscle is present in stage IV.

A client newly diagnosed with DM has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which of the following concepts? a. Always keep insulin vials refrigerated b. Ketones in the urine signify a need for less insulin c. Increase the amount of insulin before unusual exercise d. Systemically rotate insulin injections within one anatomic site

d. Systemically rotate insulin injections within one anatomic site Rationale: insulin doses should not be adjusted nor increased before unusual exercise. If ketones are found in the urine, it possibly may indicate the need for additional insulin. To minimize the discomfort associated with insulin injections, insulin should be administered at room temperature. Injection sites should be rotated systematically within one anatomic site.