Adult Health 3 Exam 4
A nurse is assessing a client who has Graves' disease. The nurse should expect which of the following laboratory results?
Decreased thyroid-stimulating hormone (TSH) level
A nurse is caring for a client who is in a myxedema coma. Which of the following actions should the nurse take?
Place the client on aspiration precautions
A client who sustained an inhalation injury arrives in the emergency department. Which of the following interventions are the nurse's priority? SATA
Provide 100% humidified oxygen Monitor oxygen saturation and level of consciousness Establish IV access Anticipate potential need for intubation
A nurse is assessing a client who is admitted with hyperthyroidism. The client reports a weight loss of 5.4 kg (12 lb) in the last 2 months, increased appetite, increased perspiration, fatigue, menstrual irregularity, and restlessness. Which of the following actions should the nurse take to prevent a thyroid crisis?
Provide a quiet, low-stimulus evnviroment
A client has been diagnosed with myxedema from long-standing hypothyroidism. Which clinical manifestations of this disorder does the nurse recognize are progressing to myxedema coma? SATA
Respiratory failure HYPOthermia HYPOtension
A nurse is caring for a preschooler who has a partial-thickness burn on their right forearm. Which of the following findings should the nurse expect? SATA
Sensitive to touch Wound blanches with pressure Blisters
A nurse is developing a plan of care for a client who is rehabilitating from major burns. Which of the following interventions should the nurse include to provide emotional support?
Talk with the client during wound care
A nurse is preparing to perform a capillary blood glucose test. Identify the sequence of steps the nurse should follow.
1.) Check expiration date on test strips 2.) Perform a quality control test 3.)Perform hand hygiene 4.) Cleanse puncture site 5.)Apply blood sample onto test strip 6.) Document results
A nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. When the nurse finds the client's blood glucose to be 48 mg/dL on the glucometer, they should give the client which of the following?
3 Graham crackers
A nurse is preparing to start an intravenous (IV) infusion of lactated ringer's for a client who sustained a burn injury. The client is prescribed 5,200 mL of fluid over the first 24 hours. How many mL/hr should the nurse set the pump to infuse for the first 8 hours?
325 ml/hr
A nurse in an emergency department is caring for a client who has burns on the front and back of both their legs and arms. Using the rule of nines, the nurse should document burns to which percentage of the client's total body surface area (TBSA)?
54 percent
A nurse is monitoring a client who was admitted with a severe burn injury and is receiving intravenous fluid resuscitation therapy. The nurse should identify which of the following findings as an indication of adequate fluid replacement? SATA
A decrease in heart rate Increase in the client's weight Increase in the urine output
A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. The nurse should recognize that the client understands the teaching when they identify which of the following as manifestations of hypoglycemia? SATA
Blurred/Double vision Tachycardia Moist, clammy skin
A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect? SATA
Increased urination Urine specific gravity 1.002
A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?
Lactated Ringers
A nurse is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should the nurse include in the teaching?
Restrict sodium intake
A nurse is assessing a client who is brought to the emergency department with burn injuries. Which of the following findings should the nurse identify as a deep partial-thickness burn?
The burned area is red in color with eschar present
A nurse is caring for a client who has diabetes and a new prescription for 14 units of regular insulin and 28 units of NPH insulin subcutaneously at breakfast daily. What is the total number of units of insulin that the nurse should prepare in the insulin syringe?
42 units
A nurse in the intensive care unit is caring for a client who is currently being treated for diabetic ketoacidosis via fluids and intravenous insulin. The client's blood glucose went from 308 to 182 mg/dL. The client's anion gap is still elevated, indicating the client is still in diabetic ketoacidosis. The nurse should anticipate which of the following prescriptions from the provider? SATA
Continue intravenous (IV) insulin drip Start the client on dextrose 5% in 0.45% NaCl intravenously
A nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the emergency department confused, flushed, and with an acetone odor on the breath. Diabetes ketoacidosis is suspected. The nurse should anticipate using which of the following types of insulin to treat this client?
Regular Insulin
A nurse in an emergency department is reviewing the medical record of a client who has an extensive burn injury. Which of the following laboratory results should the nurse expect?
HYPERkalemia
Which adverse effects should the nurse monitor for when administering intravenous insulin to a client with diabetic ketoacidosis? SATA
HYPOkalemia HYPOglycemia
A nurse is caring for a client who has diabetes insipidus and is receiving vasopressin. The nurse should identify which of the following findings as an indication that the medication is effective?
A decrease in urine output Diabetes insipidus=increased urine output Vasopressin= decreases urine output
A nurse is assessing the depth and extent of injury on a client who has severe burns to the face, neck, and upper extremities. Which of the following factors is the nurse's priority when assessing the severity of the client's burns?
Location of the burn
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
"Large incisions will be made in the eschar to improve circulation"
A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?
0.9% sodium chloride intravenous (IV) bolus
The nurse correlates which clinical manifestation with full-thickness burns?
Leathery appearance
A client has been recovering for 18 months from burns that affected 60% of total body surface area (TBSA). For which complications does the nurse provide care to this client? SATA
Depression Body image disorder Post traumatic stress disorder
The nurse recognizes which etiology as consistent with a chemical burn?
Exposure to organic compounds
The nurse is caring for a client who sustained a burn injury to the anterior arms and anterior chest area from a fire. Which assessment finding would indicate the client sustained a respiratory injury as a result of the burn? SATA
Use of accessory muscles for breathing Coughing with large black specs in sputum Black material noted in the nose and posterior pharynx Difficulty swallowing
A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?
Facial edema
A nurse is reviewing guidelines to prevent diabetic ketoacidosis (DKA) during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?
"Check your urine for ketones when blood glucose levels are greater than 240 mg/dL."
A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? SATA
Assess blood glucose level Assess for neck vein distention Weigh the client daily
A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if they have a history of which of the following conditions that can cause SIADH?
Lung malignancy
A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take?
Teach the parents about cortisol replacement therapy
A client presents to the emergency room seeking treatment for radiation burns. What needs to be considered before providing care to this client?
Type, dose andd length of exposure
A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which of the following laboratory findings indicate a therapeutic effect of the medication?
Urine specific gravity 1.015
A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect? SATA
Acetone odor to breath Kussmaul respirations
A nurse in the emergency department is caring for a client who has 30% burn injury to their lower extremities. Which of the following interventions should the nurse perform first?
Administer intravenous (IV) fluids
The nurse is preparing to administer fluid replacement for a client who has sustained significant burns. The nurse anticipates which of the following as appropriate for fluid replacement in this client? SATA
Administer lactated ringer's for half the ordered dose in 8 hours Administer lactated ringer's for a quarter of the ordered dose from 8 to 16 hours
After radiation treatment, a client reports dryness, redness, and scaling of their skin occurring within the designated radiation treatment markings. The nurse should instruct the client to take which of the following actions?
Apply hydrating lotions
A client has been admitted to the critical care unit with a diagnosis of thyroid storm. What interventions should the nurse include in the client's immediate care? SATA
Applying interventions to reduce the client's temperature Administering beta blockers to reduce the heart rate
A nurse is assessing a client following the application of an aquathermia pad. Which of the following is the first indication to the nurse that the client is experiencing a superficial burn injury to the application site?
Erythema
A client with type 2 diabetes mellitus is brought to the emergency department by their family. The client is found to have a blood glucose level of 600 mg/dL. The client's family reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action should be a priority?
Fluid and electrolyte replacement
A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to their chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the emergent phase of injury?
Maintain the airway
