ADN 120 Final exam

Which medication classifications are examples of chemical restraints? Select all that apply. A. Antianxiety B. Antipsychotic C. Antidepressant D. Nonsedative hypnotic E. Nonsteroidal anti-inflammatory drugs (NSAIDs)

A. Antianxiety B. Antipsychotic C. Antidepressant

The nurse instructs a client taking a potassium-retaining diuretic about foods high in potassium that need to be avoided. The nurse determines that the client needs further instruction if the client states that which food is high in potassium? A. Kiwi B. Celery C. Oranges D. Dried fruit

B. Celery

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding would the nurse expect to note? A. Bradycardia B. Changes in mental status C. An elevated blood pressure D. Bilateral crackles in the lungs

B. Changes in mental status

The client has sickle cell anemia and is admitted with a crisis. What treatment should the nurse anticipate? A. Give iron supplement. B. Encourage oral fluids. C. Apply cold compresses. D. Administer nonsteroidal anti-inflammatory drugs (NSAIDs).

B. Encourage oral fluids.

The client has had a nasogastric tube attached to low continuous suction for 2 days. An arterial blood gas value is drawn, and the results are as follows: pH 7.48, Paco2 40 mm Hg, and HCO3 30 mEq/L (30 mmol/L). The nurse recognizes that the client is experiencing which acid-base imbalance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

B. Metabolic alkalosis

A client has a diagnosis of hyperphosphatemia. The nurse should tell the client to avoid consuming which food item? A. Tea B. Milk C. Coffee D. Grape juice

B. Milk

The nurse is caring for a child who experienced significant blood loss from surgery. What is the nurse's priority action when caring for this child? A. Monitor the child's temperature and white blood cell (WBC) count. B. Monitor the child's intake and output (I & O) along with blood pressure. C. Review the child's most recent urinalysis and basic metabolic panel results. D. Encourage the child's parents and siblings to stay with the child as much as possible.

B. Monitor the child's intake and output (I & O) along with blood pressure.

The nurse is reviewing the laboratory results of a client with bladder cancer and bone metastasis and notes that the calcium level is 15 mg/dL (3.75 mmol/L). Which nursing action is most appropriate? A. Document the findings. B. Notify the health care provider. C. File the report in the client's record. D. Increase calcium-containing foods in the diet.

B. Notify the health care provider.

The client with acute pancreatitis presents to the emergency department. What is the priority assessment? A. Pain rating B. Orthostatic vital signs C. Recent alcohol intake D. Presence of cola-colored urine

B. Orthostatic vital signs

A client at 10 weeks' gestation has type 1 diabetes mellitus and is receiving prenatal care at a high-risk clinic. The nurse teaches the client about the early signs of hyperglycemia and should tell the client that which is an early sign? A. Hunger B. Polyuria C. Shakiness D. Nervousness

B. Polyuria

A 12-year-old with diabetes mellitus enters the emergency department complaining of extreme thirst and weakness with a respiratory rate of 32 breaths/min. The child's skin is warm and dry, and his mother states he has been urinating very frequently. What is the nurse's priority action? A. Apply a cooling blanket. B. Start a peripheral intravenous (IV) line. C. Instruct the child to breathe into a paper bag. D. Encourage the child to drink the prescribed electrolyte and glucose solution.

B. Start a peripheral intravenous (IV) line.

The nurse is performing a skin assessment on a client and checks the client's skin for turgor. The nurse grasps a fold of the client's skin in which body area to best assess turgor? A. Sacral area B. Sternal area C. Top of the foot D. Back of the hand

B. Sternal area

An adult client with heart failure (HF) has been prescribed furosemide for fluid overload and is at risk for potassium imbalance. What actions should the nurse teach the client to prevent this imbalance? Select all that apply. A. Drink at least 3.5 L of fluid daily. B. Take the potassium supplements that have been prescribed. C. Decrease the dose of the medication by half if symptoms appear. D. If symptoms of potassium imbalance appear, take the prescribed digoxin every other day. E. Know the symptoms of decreased potassium levels, for example, muscle weakness and heart irregularity. F. Eat foods high in potassium, for example, tomatoes, beans, prunes, avocados, bananas, strawberries, and lettuce.

B. Take the potassium supplements that have been prescribed. E. Know the symptoms of decreased potassium levels, for example, muscle weakness and heart irregularity. F. Eat foods high in potassium, for example, tomatoes, beans, prunes, avocados, bananas, strawberries, and lettuce.

The client presents to the emergency department with severe vomiting and diarrhea and is diagnosed with gastroenteritis. Which occurrence is most important before allowing the client to be discharged home? A. Bowel sounds within normal limits B. The client's ability to tolerate oral fluids C. Administration of antidiarrheal medication D. The client's ability to demonstrate knowledge of prescribed diet

B. The client's ability to tolerate oral fluids

The nurse is caring for a client who has a fever and is diaphoretic. The nurse monitors the client's intake and output and expects which finding? A. The client's urine is diluted. B. The client's output is decreased. C. The client's urine production is increased. D. The majority of the client's fluid is excreted through the skin.

B. The client's output is decreased.

A client has been prescribed clozapine after other atypical antipsychotic medications failed to produce acceptable management of schizophrenic-related symptomology. At what point should the nurse alert the client's health care provider to the possible need to adjust the client's medication therapy plan? A. When the client begins to demonstrate fine facial tremors B. When the client reports having a sore throat and mouth sores C. When the client finds it difficult to sleep at night but naps during the day D. When the client demonstrates paranoid ideations regarding certain staff members

B. When the client reports having a sore throat and mouth sores

A client whose magnesium level is 4 mg/dL (1.6 mmol/L) is being treated for the imbalance. The nurse determines that the electrolyte imbalance is resolving if the client has relief from which sign or symptom characteristic of this electrolyte imbalance? A. Tetany B. Twitches C. Muscular excitability D. Loss of deep tendon reflexes

D. Loss of deep tendon reflexes

When reviewing a client's laboratory results, which result should be of most concern to the nurse? A. Sodium 143 mEq/L B. Phosphate 2.6 mg/dL C. Potassium 5 mEq/L D. Magnesium 1.1 mg/dL

D. Magnesium 1.1 mg/dL

Following an open appendectomy procedure, a school-aged child complains of nausea. What is the nurse's priority action? A. Remove the nasogastric (NG) tube. B. Provide meticulous skin care when changing the abdominal dressing. C. Insert a second intravenous (IV) line for the administration of antiemetics. D. Maintain the child's nothing-by-mouth (NPO) status and administer prescribed intravenous (IV) fluids.

D. Maintain the child's nothing-by-mouth (NPO) status and administer prescribed intravenous (IV) fluids.

A client with chronic kidney disease returns to the nursing unit after receiving his second hemodialysis treatment; the nurse is monitoring the client closely for signs of disequilibrium syndrome. What is a sign of this syndrome? A. Irritability B. Tachycardia C. Hypothermia D. Mental confusion

D. Mental confusion

The nurse is monitoring a newborn of a mother with diabetes mellitus. The nurse understands that the newborn is at risk for which complication? A. Hypercalcemia B. Hyperglycemia C. Hypobilirubinemia D. Respiratory distress syndrome

D. Respiratory distress syndrome

Nursing management of the client with syndrome of inappropriate antidiuretic hormone (SIADH) includes which intervention? A. Administration of potassium supplements B. Insertion of a nasogastric tube for gastric suction C. Elevation of the head of the bed to at least 45 degrees D. Restriction of fluid intake to 1000 mL or less per day

D. Restriction of fluid intake to 1000 mL or less per day

The nurse is developing a dietary plan for a client with primary hypothyroidism. The nurse should include which most appropriate food items in the plan? A. Organ meat, carrots, and skim milk B.Seafood, spinach, and cream cheese C. Peanut butter, avocado, and red meat D. Skim milk, apples, and whole-grain bread

D. Skim milk, apples, and whole-grain bread

What is a priority nursing intervention to prevent hypothermia for a client at risk? A. Offer the client warm liquids such as tea. B. Provide the client with additional blankets. C. Close windows and doors to prevent drafts. D. Teach the client about ways to maintain warmth.

D. Teach the client about ways to maintain warmth

Which is an assessment finding in Graves' disease? A. Dry skin B. Excessive sleepiness C. Delayed linear growth D. Weight loss despite excellent appetite

D. Weight loss despite excellent appetite

A client is diagnosed with diabetic ketoacidosis. On assessment of the client, the nurse expects to note which respiratory pattern that occurs in this condition? A. Regular but abnormally sloq B. labored and increased in depth and rate C. regular but interspersed with periods of apnea D. abnormally deep and regular, with an increased rate

D. abnormally deep and regular, with an increased rate

A client newly diagnosed with type 1 diabetes mellitus is taking an intermediate-acting insulin at 0700 daily. The nurse should monitor the client closely for which signs and symptoms in the late afternoon? A. Increased appetite and abdominal pain B. Hunger, shakiness, and cool, clammy skin C. Thirst, red dry skin, and fruity breath odor D. Increased urination and rapid deep breathing

B. Hunger, shakiness, and cool, clammy skin

A client is admitted with the symptoms of dry, flushed skin; confusion; and postural hypotension. Which laboratory result should the nurse most likely expect to note? A. Hyperkalemia B. Hyponatremia C. Hypercalcemia D. Hypermagnesemia

B. Hyponatremia

The nurse is preparing to care for a pediatric client with an intravenous solution infusing. The nurse should ensure that which item is in place to prevent fluid overload in this client? A. Armboard B. Infusion pump C. Macrodrip infusion set D. Large-bore intravenous catheter

B. Infusion pump

A clear liquid diet has been prescribed for a client. The nurse should offer which item to the client? A. Apple juice B. Orange juice C. Tomato juice D. Ice cream without nuts

A. Apple juice

The nurse is reviewing the laboratory results of a client with cancer and notes that the calcium level is 14 mg/dL (3.5 mmol/L). The nurse determines that this calcium level is consistent with which oncological emergency? A. Hypercalcemia B. Tumor lysis syndrome C. Spinal cord compression D. Superior vena cava syndrome

A. Hypercalcemia

A client with severe hyponatremia is being treated with intravenous hypertonic saline (3%). The nurse determines that the treatment is effective when the laboratory results reveal which sodium level? A. 120 mEq/L (120 mmol/L) B. 130 mEq/L (130 mmol/L) C. 140 mEq/L (140 mmol/L) D. 150 mEq/L (150 mmol/L)

C. 140 mEq/L (140 mmol/L)

A client diagnosed with schizophrenia is demonstrating the classic behaviors associated with a psychotic relapse. How should the nurse best assess the client's current potential to be violent? A. Arrange for one-on-one observation of the client. B. Ask the client, "What are your voices saying to you?" C. Ask family members if the client is generally an angry, aggressive person. D. Review the client's medical record to determine when the behaviors began.

B. Ask the client, "What are your voices saying to you?"

The nurse notes that a client's serum potassium level is 5.8 mEq/L (5.8 mmol/L). The nurse interprets that this is an expected finding in the client with which problem? A. Diarrhea B. Burn injury C. Diabetes insipidus D. Pulmonary edema being treated with loop diuretics

B. Burn injury

A child newly diagnosed with type 1 diabetes mellitus who is receiving insulin suddenly experiences signs of a hypoglycemic reaction. Which item should the nurse give to the child immediately? A. 8 oz (225 mL) of skim milk B. ½ cup of diet cola C. 1 teaspoon of honey D. 1 teaspoon of sugar

A. 8 oz (225 mL) of skim milk

A client has been admitted to the acute care unit with a diagnosis of thyroid storm. What is the priority nursing intervention? A. Administer antipyretic medications, as prescribed. B. Identify stressors that may have triggered the condition. C. Begin a continuous infusion of normal saline 0.9% at keep vein open (KVO) rate. D. Obtain a blood specimen to evaluate levels of thyroid-stimulating hormone (TSH), T3, and T4.

A. Administer antipyretic medications, as prescribed.

The nurse is caring for a client receiving infusion therapy. What are the most common reasons for using infusion therapy on clients? Select all that apply. A. Administration of medications B. Decreasing costs of health care C. Replacement of blood or blood products D. Decreasing length of stay of hospitalized clients E. Maintenance of fluid balance or correct of fluid imbalance F. Maintenance of electrolyte or acid-base balance or correction of electrolyte or acid-base imbalance

A. Administration of medications C. Replacement of blood or blood products E. Maintenance of fluid balance or correct of fluid imbalance F. Maintenance of electrolyte or acid-base balance or correction of electrolyte or acid-base imbalance

The nurse is teaching the family of an adolescent newly diagnosed with type 2 diabetes mellitus about the disorder. The parents verbalize understanding of the teaching if which statement is made? A. "I should begin to look for a fitness program for my child." B. "I'll give my child insulin as soon as I notice that he gets irritable and sweaty." C. "This condition was caused by the inability of the pancreas to produce insulin." D. "If I administer insulin as prescribed, my child will not suffer any long-term complications."

A. "I should begin to look for a fitness program for my child."

At 0700, the nurse administers insulin lispro to a client with type 1 diabetes mellitus. What is the most important time period for the nurse to monitor the client for hypoglycemia? A. 0730 to 0930 B. 1000 to 1300 C. 1430 to 1730 D.1800 to 2100

A. 0730 to 0930

The nurse is assessing the extent of pitting edema in a client with heart failure. The nurse gently presses a finger on the client's ankle and notes a barely perceptible pitting. The nurse interprets this finding as which measurement of pitting edema? A. 1+ B. 2+ C. 3+ D. 4+

A. 1+

What interventions should the nurse take for a client with schizophrenia to manage comorbid disorders? Select all that apply. A. Assess the client for suicidal ideations. B. Encourage the client to avoid highly spiced foods. C. Monitor and document the client's blood pressure. D. Reinforce the client's ability to implement anxiety reduction techniques. E. Support the client's efforts to stop smoking or chewing tobacco products.

A. Assess the client for suicidal ideations. C. Monitor and document the client's blood pressure. D. Reinforce the client's ability to implement anxiety reduction techniques. E. Support the client's efforts to stop smoking or chewing tobacco products.

A hospitalized client with chronic kidney disease has returned to the nursing unit after a hemodialysis treatment. The nurse should check predialysis and postdialysis documentation of which parameters to determine the effectiveness of the procedure? A. Blood pressure and weight B. Weight and blood urea nitrogen C. Potassium level and creatinine levels D. Blood urea nitrogen and creatinine levels

A. Blood pressure and weight

The nurse looks at a telephone laboratory report and notes that a client's serum potassium level is 5.5 mEq/L (5.5 mmol/L). Based on this laboratory result, the nurse should take which most appropriate action? A. Contact the health care provider. B. Administer the prescribed potassium chloride. C. Instruct the client to include high-potassium foods in the diet. D. Call the dietary department and request that a banana or a glass of orange juice be delivered to the client daily.

A. Contact the health care provider.

The nurse is reviewing the laboratory results of a client and notes that the serum sodium level is 150 mEq/L (150 mmol/L). The nurse understands that this laboratory result would be noted in a client who had which condition? A. Dehydration B. Addison's disease C. A severe burn injury D. Adrenal insufficiency

A. Dehydration

The nurse is assessing the client after having a fractured hip repaired. The client is exhibiting symptoms of confusion, which came on rapidly after surgery. The client is also exhibiting hallucinations. Which syndrome is this client most likely experiencing? A. Delirium B. Dementia C. Depression D. Alzheimer's disease

A. Delirium

The client presents with these findings: constipation, polyuria, tachycardia, and serum osmolality of 325 mOsm/kg (325 mmol/kg) and urine specific gravity of 1.000. The nurse would be correct to suspect which disorder? A. Diabetes insipidus B. Hyperparathyroidism C. Hyperglycemic-hyperosmolar state (HHS) D. Syndrome of inappropriate antidiuretic hormone (SIADH)

A. Diabetes insipidus

The nurse is preparing to insert a peripheral intravenous catheter into a client. What areas on the client does the nurse know to avoid? Select all that apply. A. Edematous extremity B. A nonparalyzed arm C. A skin area that is infected D. The arm on the same side as a mastectomy E. An arm that has an arteriovenous fistula/shunt for dialysis F. An arm with a peripherally inserted intravenous catheter already in place

A. Edematous extremity C. A skin area that is infected D. The arm on the same side as a mastectomy E. An arm that has an arteriovenous fistula/shunt for dialysis

The nurse managing the care of a client diagnosed with schizophrenia should include which intervention into the client's plan of care after being prescribed a conventional (non-atypical) antipsychotic medication? Select all that apply. A. Encourage the client to chew gum. B. Assess the client for possible urinary retention. C. Educate the client to the increased risk of developing hyperglycemia. D. Monitor the client's menu selections to ensure adequate fiber consumption. E. Provide the client with sunglasses when being taken outdoors for recreational walks.

A. Encourage the client to chew gum. B. Assess the client for possible urinary retention. D. Monitor the client's menu selections to ensure adequate fiber consumption. E. Provide the client with sunglasses when being taken outdoors for recreational walks.

The nurse reviews the serum laboratory study results for a client taking hydrochlorothiazide. The nurse should monitor for which most frequent medication side effect? A. Hypokalemia B. Hypocalcemia C. Hypernatremia D. Hyperphosphatemia

A. Hypokalemia

A young adult is being evaluated for a possible eating disorder. Which nursing intervention is most directly related to a commonly observed complication related to bulimia nervosa? A. Increasing potassium-rich foods in the daily diet B. Adding fiber to the diet to help minimize constipation C. Medicating the client for migraine headaches as they occur D. Monitoring the client for signs of developing contact dermatitis

A. Increasing potassium-rich foods in the daily diet

Which are consequences of cold stress the nurse may observe in a newborn infant? Select all that apply. A. Jaundice B. Hypoglycemia C. Cephalhematoma D. Erythema toxicum E. Respiratory distress

A. Jaundice B. Hypoglycemia E. Respiratory distress

The nurse develops a plan of care for a client with a new diagnosis of Graves' disease. The nurse should include which intervention in the plan of care? A. Keep the room temperature cool. B. Place extra blankets on the client's bed. C. Provide a diet low in calories and protein. D. Encourage frequent ambulation and other physical activities.

A. Keep the room temperature cool.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment would elicit specific information regarding the client's left-sided heart function? A. Listening to lung sounds B. Monitoring for organomegaly C. Assessing for jugular vein distention D. Assessing for peripheral and sacral edema

A. Listening to lung sounds

The nurse is reviewing medication prescriptions for a newly admitted client with type 1 diabetes mellitus. Which prescription should the nurse clarify with the health care provider? A. Metformin 500 mg by mouth two times per day B. Insulin glargine 10 units subcutaneously at bedtime C. Lispro insulin sliding scale before meals and at bedtime D. Dextrose 50% ampule intravenous push for blood glucose less than 50 mg/dL

A. Metformin 500 mg by mouth two times per day

The nurse is reviewing the laboratory results of a client and notes that the client has a magnesium level of 1.3 mg/dL (0.5 mmol/L). What is the most appropriate nursing action? A. Monitor the client for dysrhythmias. B. Encourage increased intake of phosphorus antacids. C. Instruct the client to increase the consumption of foods low in magnesium. D. Consult with the health care provider about the need to discontinue magnesium intake.

A. Monitor the client for dysrhythmias.

The nurse is assigned to care for a client who is taking furosemide. The nurse determines it is important to monitor the client's intake and output (I&O). When measuring output, which actions should the nurse take? Select all that apply. A. Note all types of output on the I&O sheet. B. Perform hand hygiene, and apply sterile gloves. C. Ask for the client's permission to measure output. D. Use a graduated cylinder to obtain measurement. E. Write down the amount immediately after measuring.

A. Note all types of output on the I&O sheet. D. Use a graduated cylinder to obtain measurement. E. Write down the amount immediately after measuring.

The client is prescribed to receive Humulin N insulin at 0700. To reduce the risk of hypoglycemia, the nurse should perform which action? A. Offer the client a snack around 10:00. B. Hold the insulin dose if the client's blood glucose is less than 150 mg/dL (8.3 mmol/L). C. Question the health care provider regarding the time of the dosing schedule. D. Keep 50% dextrose intravenous (IV) solution available at the bedside at all times.

A. Offer the client a snack around 10:00.

The client states he is having difficulty keeping his blood glucose under control with his usual dosage of insulin. The nurse should assess what factors to evaluate possible reasons for this recent change? Select all that apply. A. Recent history of illness B. Reduced carbohydrate intake C. Calibration of the glucometer D. Location of insulin administration E. Increase in the intensity of exercise

A. Recent history of illness C. Calibration of the glucometer D. Location of insulin administration

Which assessment finding should the nurse expect to note in a child with hypovolemic shock? A. Reduced urinary output B. Elevated blood pressure C. Brisk capillary refill time D. Elevated central venous pressure (CVP)

A. Reduced urinary output

A client is taking a thyroid hormone replacement medication. The nurse knows that thyroid hormones have which effects? Select all that apply. A. Stimulate the heart. B. Promote bradycardia. C. Encourage energy use. D. Reduce heat production. E. Promote growth and development.

A. Stimulate the heart. C. Encourage energy use. E. Promote growth and development.

The nurse notes documentation in a client's medical record that the client is experiencing anuria. Based on this notation, what determination should the nurse make? A. The client is unable to produce urine. B. The client has a diminished capacity to form urine. C. The client has difficulty having a bowel movement. D. The client has episodes of alternating constipation and diarrhea.

A. The client is unable to produce urine.

The nurse is teaching a new diabetic client and the family of the client about the disorder. What steps should the nurse include in the teaching process? Select all that apply. A. Use the teach-back method or return demonstration when appropriate. B. Spend time teaching clients who are showing signs of compliance only. C. Document the teaching and what was taught during the teaching session. D. Document who was present and evaluation of understanding of the teaching. E. Explain to the client what could happen if information shared during teaching is not followed. F. Determine what it means to the client and family to have diabetes in a language they understand.

A. Use the teach-back method or return demonstration when appropriate. C. Document the teaching and what was taught during the teaching session. D. Document who was present and evaluation of understanding of the teaching. E. Explain to the client what could happen if information shared during teaching is not followed. F. Determine what it means to the client and family to have diabetes in a language they understand.

The nurse is reviewing a client's admission laboratory results and notes that the client's serum calcium level is 14 mg/dL (3.5 mmol/L). The nurse should check to see that which medication that may be prescribed is available in the stock medication supply area on the clinical nursing unit? A. Vitamin D B. Calcitonin C. Calcium chloride D. Calcium gluconate

B. Calcitonin

The client has a T3 spinal cord injury and is brought to the emergency department. The nursing assessment reveals blood pressure 70/40 mm Hg, pulse 50 beats/min, and respirations 18 breaths/min, and the nurse suspects neurogenic shock. The client's skin is warm, dry, and pink. What action should the nurse prepare to take first? A. Assess cranial nerves X and XI. B. Administer intravenous isotonic fluids. C. Place the client in Trendelenburg's position. D. Perform a Glasgow Coma Scale assessment.

B. Administer intravenous isotonic fluids.

A client with hypertension and diabetes mellitus is to start taking propranolol as part of his daily medication regimen. Which statement indicates an understanding of this medication? A. "This medication will result in needing less insulin each day." B. "I will be sure to pay close attention for symptoms of hypoglycemia." C. "This medication will decrease my blood glucose, so I will need to check it more often." D. "I should notice a decrease in my blood glucose within 1 month of starting this medication."

B. "I will be sure to pay close attention for symptoms of hypoglycemia."

Which surgical client is at increased risk for a wide temperature variation during surgery? A. A 19-year-old client scheduled for arthroscopy B. A 3-month-old infant scheduled for hernia repair C. A 62-year-old client scheduled for hip replacement D. A 54-year-old female scheduled for total abdominal hysterectomy

B. A 3-month-old infant scheduled for hernia repair

What factor affecting heat loss by convection should the nurse be aware of when giving a client a bath? A. The time the bath was taken B. A draft in the client's bathroom C. A cool temperature in the bathroom D. Perspiration due to the water temperature

B. A draft in the client's bathroom

The nurse is working with a nursing student in educating a newly diagnosed client with diabetes mellitus about metformin. Which statement by the nursing student, if made to the client, requires intervention by the nurse? A. "The side effects of metformin should decrease over time." B. "You should take metformin with food to decrease stomach upset." C. "If you take high doses of metformin, you will definitely develop hypoglycemia." D. "If you need a computed tomography (CT) scan, let them know that you take metformin."

C. "If you take high doses of metformin, you will definitely develop hypoglycemia."

A client states that her blood glucose at the health fair she attended yesterday was 145 mg/dL (8.1 mmol/L), and she is concerned that she will need to begin medication for diabetes mellitus. What is the best response by the nurse? A. "I am sure everything is fine; you are not overweight." B. "Is there a history of diabetes in your immediate family?" C. "Unless you were fasting for this test, the result does not mean you have diabetes." D. "I would recommend asking your health care provider about starting an oral hypoglycemic medication."

C. "Unless you were fasting for this test, the result does not mean you have diabetes."

The nurse is screening clients for their risk of developing type 2 diabetes mellitus. The nurse should consider which client at greatest risk? A. A client with hyperthyroidism complaining of excessive sweating B. A client with hyperlipidemia whose mother has type 2 diabetes mellitus C. A client who is obese with complaints of urinary frequency and hunger D. A client with a body mass index (BMI) of 27 with a history of hypertension and anxiety

C. A client who is obese with complaints of urinary frequency and hunger

The nurse is reviewing the laboratory results of a client and notes that the serum potassium level is 5.5 mEq/L (5.5 mmol/L). The nurse understands that this laboratory result would be noted in a client who had which condition? A. Diarrhea B. Diabetes insipidus C. Addison's disease D. Dumping syndrome

C. Addison's disease

During the administration of a blood transfusion to a client, the nurse notes the presence of crackles in the client's lung bases. On further data collection, the nurse notes that the client has distended neck veins and an increase in blood pressure. The nurse suspects that the client is experiencing what complication of the blood transfusion? A. Sepsis B. Allergic reaction C. Circulatory overload D. Transfusion reaction

C. Circulatory overload

The nurse should assess for which clinical manifestations in a client with hypothyroidism? A. Goiter, diarrhea, and hoarseness B. Anxiety, palpitations, and hair loss C. Constipation, anemia, and periorbital edema D. Fatigue, nausea, and a leg ulcer that will not heal

C. Constipation, anemia, and periorbital edema

A client begins taking a sulfonylurea once daily. The nurse should observe for which intended effect of this type of medication? A. Weight loss B. Resolution of infection C. Decreased blood glucose D. Decreased blood pressure

C. Decreased blood glucose

Which finding indicates to the nurse that vasopressin is effectively managing symptoms associated with diabetes insipidus? A. Polydipsia B. Hypotension C. Decreased urine output D. Increased serum osmolality

C. Decreased urine output

The nurse is monitoring a client with hyperparathyroidism for signs of hypercalcemia. The nurse would expect to note which finding if hypercalcemia is present? A. Paresthesias B. Positive Chvostek's sign C. Diminished bowel sounds D. Hyperactive deep tendon reflexes

C. Diminished bowel sounds

A client with a diagnosis of suspected food poisoning is admitted to the hospital because of dehydration. The nurse should expect to note which finding on assessment of this client? A. Decreased pulse B. Increased urine output C. Dry mucous membranes D. Decreased respiratory rate

C. Dry mucous membranes

The client has been diagnosed with polycystic kidney disease. The nurse should assess the client for which manifestation that is most common for this disorder? A. Headache B. Hypotension C. Flank pain and hematuria D. Complaints of low pelvic pain

C. Flank pain and hematuria

Hypoglycemia is most likely a potential effect of which oral hypoglycemic agent? A. Acarbose B. Sitagliptin C. Glipizide D. Glucophage

C. Glipizide

The nurse is caring for a client who is receiving a potassium-retaining diuretic. The nurse should monitor for which side effect of the medication? A. Dry skin B. Constipation C. Hyperkalemia D. Hypernatremia

C. Hyperkalemia

The health care provider prescribes aripiprazole for a client with a diagnosis of schizophrenia. Which nursing intervention would be therapeutic? A. Administer the medication only after meals. B. Inform the client to limit his alcohol intake to one drink each day. C. Inform the client that the medication may cause sedation and should be taken at bedtime. D. Instruct the client to increase his usual exercise pattern threefold to help with medication absorption.

C. Inform the client that the medication may cause sedation and should be taken at bedtime.

The nurse is monitoring a client for signs and symptoms of hypocalcemia. Which finding is an indication of this electrolyte imbalance? A. Lethargy B. Confusion C. Irritability D. Depressed sensorium

C. Irritability

When a client is prescribed the atypical antipsychotic medication olanzapine, the nurse will best demonstrate an understanding of its possible side effects by taking which action? A. Monitor urinary output. B. Monitor apical heart rate. C. Monitor glucose levels by fingerstick. D. Monitor peripheral pulse quality and rates.

C. Monitor glucose levels by fingerstick.

An older client is recovering after a total hip replacement. Two days after surgery, the nurse is reviewing the client's laboratory values. Which value should alert the nurse to contact the client's health care provider? A. Calcium 9.0 mg/dL (2.25 mmol/L) B. Sodium 141 mEq/L (141 mmol/L) C. Potassium 3.2 mEq/L (3.2 mmol/L) D. Total protein 65 g/L (6.5 g/dL)

C. Potassium 3.2 mEq/L (3.2 mmol/L)

A client with acute kidney injury has been treated with sodium polystyrene sulfonate by mouth. The nurse should evaluate this therapy as most effective if which value was noted on follow-up laboratory testing? A. Calcium 9.8 mg/dL (2.5 mmol/L)) B. Sodium 142 mEq/L (142 mmol/L) C. Potassium 4.9 mEq/L (4.9 mmol/L) D. Phosphorus 3.9 mg/dL (1.26 mmol/L)

C. Potassium 4.9 mEq/L (4.9 mmol/L)

The nurse caring for a client following a bowel resection notes that the client is restless. The nurse takes the client's vital signs and notes that the client's pulse rate has increased and that the blood pressure has dropped significantly since the previous readings. The nurse suspects that the client is going into shock and should take which immediate action? A. Check the client's oxygen saturation level. B. Recheck the vital signs to verify the findings. C. Raise the client's legs above the level of the heart. D. Slow the rate of the intravenous (IV) fluid infusing.

C. Raise the client's legs above the level of the heart.

A client experiencing delusions of being poisoned is admitted to the hospital. The client shows no evidence of dehydration and malnutrition at this time. The nurse prepares a plan of care for the client and should include which client need as the priority? A. Self-esteem needs B. Physiological needs C. Safety and security needs D. Love and belonging needs

C. Safety and security needs

A client's chart makes note that she has been demonstrating "all or nothing thinking." Which client behavior supports this observation? A. The client insists she was responsible for the party being poorly attended. B. The client states, "I know that my husband will be happy when I'm gone." C. The client insists on eating the whole pizza or not eating any pizza at all. D. The client states, "My father isn't capable of showing me any love or respect."

C. The client insists on eating the whole pizza or not eating any pizza at all.

The mother of a teenage son who has been engaging in exhibitionism asks, "Is there a chance that he will ever stop this behavior?" Based on the nurse's understanding of this form of paraphilia, what is the best response to this question? A. This form of paraphilia is always a precursor to rape B. This form of paraphilia always progresses into pedophilia. C. This form of paraphilia appears to resolve as the male ages. D. This form of paraphilia is always required for arousal to occur.

C. This form of paraphilia appears to resolve as the male ages.

The client with full-thickness burns over 50% total body surface is brought to the emergency department. Rapid infusion of intravenous normal saline is started. What is the best indication that the client has adequate hydration? A. Presence of tears B. Moist mucous membranes C. Urine output of 40 mL/hr D. Capillary refill less than 2 seconds

C. Urine output of 40 mL/hr

The nurse enters the room of a client with diabetes mellitus and finds the client difficult to arouse. The client's skin is cool and clammy, and the client's pulse rate is elevated from the client's baseline. The nurse immediately implements which action? A. give the client a glass of orange juice B. prepare an intravenous (IV) insulin solution C. check the client's capillary blood glucose D. administer and IV bolus dose of 50% dextrose

C. check the client's capillary blood glucose

Which statement by the client with diabetes mellitus indicates that teaching by the nurse was effective? A. "I will check my hemoglobin A1c each morning before I eat or drink anything." B. "I know my medication is working if I do not have symptoms of hypoglycemia." C. "I must call my health care provider immediately if my blood glucose is over 150 mg/dL (8.3 mmol/L)." D. "I will have a snack about 2 hours after I give myself my Humalog insulin injection."

D. "I will have a snack about 2 hours after I give myself my Humalog insulin injection."

An older woman is admitted to the acute psychiatric unit with a diagnosis of moderate depression. The client is unclean, her hair is uncombed, and she is inappropriately dressed. She is accompanied by her adult daughter who is very upset about her mother's lack of interest in her appearance. The nurse appropriately alleviates the daughter's concern by making which statement? A. "Hygiene is not important to those who are depressed." B. "Client self-esteem needs take priority over appearances." C. "Group peer pressure on the unit will soon have your mother attending to her hygiene needs." D. "The nurses will assist your mother in meeting hygiene needs until she is able to resume self-care."

D. "The nurses will assist your mother in meeting hygiene needs until she is able to resume self-care."

The nurse notes that a child with Hirschsprung disease who is scheduled for surgery has inadequate fluid volume. The nurse should plan to implement which intervention to stabilize the child's hydration status before surgery? A. Monitor daily weight. B. Monitor intake and output. C. Administer tap water enemas. D. Administer intravenous fluids and electrolytes.

D. Administer intravenous fluids and electrolytes

The nurse is monitoring a client who is experiencing vomiting and diarrhea for signs of dehydration. What is the best indication that the client is dehydrated? A. Sodium: 135 mEq/L (135 mmol/L) B. Hemoglobin: 10 g/dL (100 mmol/L) C. Urine specific gravity: 1.005 D. Blood urea nitrogen (BUN): 30 mg/dL (10.7 mmol/L)

D. Blood urea nitrogen (BUN): 30 mg/dL (10.7 mmol/L)

The client with acute pancreatitis has an elevated amylase and lipase that is 5 times the normal value. What assessment finding is most important for the nurse to address? A. Client is lying in a fetal-like position. B. Pain rated "7" in the left upper quadrant C. Gray-blue discoloration around the umbilicus D. Cheek has a muscle spasm when the mastoid is tapped.

D. Cheek has a muscle spasm when the mastoid is tapped.

The nurse is caring for a client with a diagnosis of cirrhosis of the liver and is monitoring the client for signs of portal hypertension. Which initial sign, if noted in the client, indicates the presence of portal hypertension? A. Weak pulse B. Hypotension C. Flat neck veins D. Crackles on auscultation of the lungs

D. Crackles on auscultation of the lungs

A client has been newly diagnosed with diabetes mellitus. The nurse should perform which action as the first step in teaching the client about the disorder? A. Decide on the teaching approach. B.Plan for the evaluation of the session. C. Gather all available resource materials. D. Identify the client's knowledge and needs.

D. Identify the client's knowledge and needs.

A client is taking amiloride hydrochloride daily. The nurse should tell the client to take the dose at what time? A. At bedtime B. On an empty stomach C. Between lunch and dinner D. In the morning with breakfast

D. In the morning with breakfast

The client is brought from a burning building and has hard leathery black skin over the entire chest and both arms. What is the client's primary need in the emergency department? A. Analgesics B. Debridement C. Tetanus immunization D. Intravenous (IV) fluids

D. Intravenous (IV) fluids