ATI Med Surg sarita

A nurse is reviewing guidelines to prevent 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 keytone when blood glucose levels are greater than 240 mg/dl" The client should check his urine for ketones when blood glucose levels are greater than 240mg/dL in order to detect DKA. The client should contact the provider if he has moderate or large amounts of ketones in his urine

A nurse is providing teaching about a heart healthy diet to a group of clients with hypertension. Which of the following statements by one of the clients indicates a need for further teaching

"I may eat 10 ounces of lean protein each day. Lean meats should be limited to 5 to 6 oz per day. This statement by a client requires additional teaching.

A nurse is teaching a client who has acute kidney injury about dietary sources of potassium. Which of the following statements by the client indicated a need for clarification?

"adding pecans will be a change i can readily make" Pecans do not contain high levels of potassium. Pistachios are a good choice of a nut that is high in potassium

A staff nurse is teaching a client who has Addison's disease about the disease process. The client asks the nurse what causes Addison's disease. Which of the following responses should the nurse make?

"it is caused by the lack of production of aldosterone by the adrenal gland" Addison's disease is caused by a lack of production of the adrenocorticotropin hormones (cortisol & aldosterone) by the adrenal gland

A nurse is caring for a client who has Cushing's syndrome. The nurse should recognize that which of the following are manifestations of Cushing's syndrome? (Select all that apply.)

*Alopecia; clients who have Cushing's disease develop hirsutism, which is excessive body hair. Women can also develop alopecia, in the form of male pattern baldness *Moon Face: which is manifested by a round, red, full face *Purple striations: on the skin of the abd, thighs, and breasts.

A nurse in an ER 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 IV bolus The nurse should expect a prescription for an IV bolus 0.9% sodium chloride to be administered at 15-20 mL/kg/hr for the first hour to restore volume and maintain perfusion to the vital organs

A nurse is monitoring a client who is postoperative following a thyroidectomy. Which of the following data should the nurse identify as the priority to monitor?

Airway Patency When using the airway, breathing, circulation approach to client care, the nurse should determine it is the priority to monitor the client's airway. Nerve damage, hypocalcemia induced tetany, and edema can all impair the airway following thyroidectomy

A nurse is caring for a client who has Cushing's syndrome. Which of the following interventions should the nurse expect to perform? select all that apply

Assess blood glucose level, neck vein distension, and weigh daily Cushing's syndrome affects blood glucose levels by causing increased release of glucose from the liver and decreased sensitivity of insulin receptors. This can result in elevated blood glucose levels. May be helpful to monitow daily weight, I&O, maintain low sodium diet, extremities for edema

a client is starting celecoxib to treat osteoarthritis. THe nurse should instruct the client to watch for and report which of the following adverse effects?

Black, tarry stools Celecoxib can cause GI bleeding. The client should watch for and report, black, dark-colored, or bloody stools, abdominal pain, or coffee-ground emesis. The nurse should instruct the client to take ccelecoxib with food to reduce gastric irritation

a nurse is planning care for a client who is post-operative following a thyroidectomy. Which of the following interventions should the nurse include in the plan?

Check the clients voice every 2 hours -the nurse should assess the client's voice every 2 hours to monitor for horses, which is the manifestation of laryngeal nerve damage

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

Edema An increase venous hydrostatic pressure, which develops when fluid accumulates in the veins, causes fluid to leak out into the tissues resulting in edema

A nurse is caring for client who is postoperative following hip arthroplasty. The nurse should anticipate which of the following prescriptions for this client?

Enoxaparin The nurse should anticipate a prescription for enoxaparin as prophylaxis therapy for venous thromboembolism. Clients following hip arthroplasty are usually on anticoagulants for 3 to 6 weeks after surgery

A nurse is caring for an older adult client who has rheumatoid arthritis (RA) and is taking aspirin 650 mg every 4 hours. Which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness of this medication?

Erythrocyte sedimentation rate (ESR) RA is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. as the disease improves the EST decreases

A nurse is caring for a client 4 hr following a cardiac catheterization. Which of the following actions should thenurse take?

Have the client lie flat in bed. The nurse should have the client on lie flat in bed. Clients who had manual or mechanicalpressure after catheter removal require 6 hr of bed rest. Those who had a closure device orpatch only need 2 hr of bed rest.

A nurse is completing an assessment on a client who is admitted for elective surgery and has a history of Addison's disease. Which of the following findings should the nurse expect?

Hyperpigmentation Addison's disease is an endocrine disorder that occurs when the adrenal glands do not produce enough of the hormone cortisol, and in some cases, the hormone aldosterone. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and non-exposed parts of the body.

a nurse is assessing a client who has cushing's disease. which of the following findings should the nurse expect?

Hyperpigmentation Hyperpigmentation, bruising, and striae or stretch marks, are manifestations of Cushing's syndrome

a nurse is caring for a client 1 day postoperative who has developed atelectasis. which of the following manifestations is an expected findings for this condition

Hypoxemia The nurse can expect to find the client with hypoxemia, which is decreased oxygenation of the red blood cells and cyanosis due to poor oxygen exchange

a nurse is completing discharge instructions with a client following an acute onset of gout. Which of the following client statements indicates an understanding of the treatment regimen?

I will limit my alcohol intake A client who has gout should limits alcohol consumption, which is known to cause a gouty attack by inhibiting excretion of uric and leading to its buildup. However, clients should be encouraged to increase their fluid intake to help prevent formation or urinary stones

A nurse is caring for a client who is 1-day postoperative following total hip arthroplasty. It is 0830 and the client is schedule for physical therapy (PT) at 0900. Which of the following interventions should the nurse take?

Identify the client's pain level and medicate if needed The client should have adequate pain medication and pain relief 20 to 30 min before PT sessions so he can work effectively with the therapist

A nurse is providing teaching to a client who has angina pectoris and a new prescription for nitroglycerin sublingual tablets. Which of the following statements by the client indicates an understanding of the teaching?

If 1 nitroglycerin tablet does not relieve the client's pain, he should access emergency services and then take 2 more tablets at 5 min intervals if he still has pain

A nurse is providing preoperative teaching for a client who is scheduled for a gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in the teaching?

Instruct the client about the use of a sequential compression device The nurse should instruct the client the use a sequential compression device to prevent deep-vein thrombosis, a postoperative complication

A nurse on a med-surg unit is caring for a client who reports pain in the jaw, back, and shoulder; shortness of breath and nausea. Which of the following actions should the nurse take?

Obtain an EKG The nurse should obtain en EKG to detect heart rhythm abnormalities within 10 min of the client's reported discomfort

A nurse is caring for a client who is postoperative following an open reduction and internal fixation of a fractured femur. Which of the following actions is the most important for the nurse to complete in the postoperative period?

Perform neurovascular checks of the extremities The priority action the nurse should take when using the airway, breathing, circulation approach to client care is the performance of neurovascular checks, there are a vital aspect for the client who has a sustained a fracture and should be monitored every hour for the first 24 hour. Circulations can easily become impaired due to constriction, which develops as the extremity swells from edema. This may cause nerve damage and tissue anoxia.

A nurse is teaching a client about medications that prevent osteoporosis. The nurse should instruct the client that which of the following medications is prescribed to prevent osteoporosis?

Raloxifene Raloxifene is prescribed for the prevention and treatment of osteoporosis in postmenopausal women.

A nurse is talking to a client who is taking a calcium supplement for osteoporosis. The client tells the nurse she is experiencing flank pain. Which of the following adverse effects should the nurse suspect?

Renal stones Hypercalcemia due to calcium supplements can cause renal stones. Clients should increase their water intake while taking calcium supplements to hydrate the kidneys and should report any blood in the urine or flank pain

A nursing 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 The nurse should recommend the client to restrict intake to control fluid volume. This restriction can range from "non-added-salt" to table foods to a restriction of 2g/day

Nurse is caring for a pt who is 8hr post op following a subtotal thyroidectomy. In which of the following positions should the nurse keep the client?

Semi fowlers with the neck in a neutral position -It is the most comfortable position for a pt who had thyroid surgery. Neck flexion could compromise the airway, and neck extension could place excessive tension on the operative area and the suture. A neutral position is essential.

A nurse is reviewing the laboratory report of a client and identifies a serum potassium level of 6.8 mEq/L. Which of the following medications should the nurse plan to administer?

Sodium polystyrene used to treat hyperkalemia by removing excess potassium by ion exchange through the bowel

A nurse is providing teaching to a client who has stable angina and a new prescription for nitroglycerin oral, sustained release capsules. Which of the following instructions should the nurse include

Swallow the capsules whole The client should swallow the capsules whole and not chew or crush them or place them under tongue

A nurse is caring for a client who has Addison's disease and is at risk for Addison crisis. Nursing care of this client should include which of the following nursing actions

Take Daily Weight: Addison's disease is an endocrine disorder that occurs in all age groups and affects men and women equally. The disease is characterized by weight loss, muscle weakness, fatigue, low blood pressure, and hyperpigmentation (darkening) of the skin in both exposed and unexposed parts of the body. Daily weight will alert the nurse that dehydration is occurring, which could indicate an impending crisis

A nurse is establishing health promotion goals for a female client who smokes cigarettes, has hypertension, and has a BMI of 26. Which of the following goals should the nurse include?

The client will walk for 30 min 5 days a week CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week

A nurse is talking with a client whose thyroid stimulating hormone (TSH) level will be measured. Which of the following statements by the nurse explains the purpose of this test?

This test determines whether your thyroid gland is overactive, appropriately active, or under active" This test helps determine thyroid status and helps monitor the effectiveness and dosage of thyroid hormone replacement therapy

A nurse in a clinic is reviewing the lab values of a client who has primary hypothyroidism. The nurse should anticipate an elevation of which of the following lab values?

Thyroid Stimulating hormones (TSH)

A nurse is caring for a client who had total thyroidectomy and a serum calcium level of 7.6 mg/dl. Which of the following fings should the nurse expect?

Tingling of the extremities. -Serum calcium level of 7.6 is below the expected reference range, indicating hypocalcemia. The nurse should monitor the client for reports of tingling and numbness of the extremities and around the mouth, muscle tremors, cramps and cardiac dysryhythmias

A nurse is caring for a client who sustained blood loss. Which of the following is a manifestation of hypovolemia?

Weak Pulse A decreased volume of circulating blood and less pressure within the vessels results in a weak peripheral pulses, which can be described as thready

A nurse is reviewing the EKG strip of a client who has prolonged vomiting. Which of the following abnormalities on the client's EKG should the nurse interpret as a sign of hypokalemia?

abnormally prominent U wave; although U waves are rare, their presence can be associated with hypokalemia, hypertension and heart disease. For a client who has hypokalemia, the nurse should monitor the EKG strop for a flattened T wave, prolonged PR interval, prominent U wave or ST depression

A nurse is preparing to administer verapamil by IV bolus to a client who is having cardiac dysrhythmias. For which of the following adverse effects should the nurse monitor when giving this medication?

hypotension Verapamil, a calcium channel blocker, can be used to control supraventricular tachyarrhytmias. It also decreases blood pressure and acts as a coronary vasodilator and antianginal agent. A major side effect of verapamil is hypotension; therefore, blood pressure and pulse must be monitored before and during parenteral administration

a nurse is assessing a client who is receiving liothyronine for treatment of hypothyroidism. The nurse should recognize which of the following findings is a therapeutic response to this medication?

increase in energy -an increase in energy is the therapeutic response to liothyronine. Depression, lethargy, and fatigue are manifestations of hypothyroidism and effective treatment will improve these manifestations

a nurse is assessing a client who is admitted with hyperthyroidism. the client reports a weight loss of 5/4 kg (12lb) 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 environment A thyroid crisis can occur in response to a stressor, so the nurse should minimize stressful stimuli in the client's environment.

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take?(select all that apply)

teach the client to use the call light -Keep the client's bed in the lowest position. -place a fall-risk identification band on the client's wrist

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 -the nurse should plan to teach the child's parents about cortisol replacement therapy. Administration of glucocorticoids and mineralocorticoids is necessary because inadequate supplies of a sudden cessation of the medications can cause acute adrenal crisis.

a nurse is caring for a client who is 1-day post-operative following a thyroidectomy reports severe muscle spasms of the lower extremities. Which of the following actions should the nurse take?

verify the most recent calcium level -the client who has had a thyroidectomy is at risk of hypocalcemia due to the possible disruption of the parathyroid gland during surgery. The parathyroid glands are the four small glands located inside the thyroid gland that are responsible for calcium regulation. If they are damaged during a thyroidectomy, there is a risk of hypocalcemia. low calcium levels can be manifested as numbness and tingling of the fingers and around the mouth, muscle spasms particularly of the hands and feet, and hyperactive reflexes. If a client develops any of these manifestations following a thyroidectomy, the nurse should check the clients latest calcium level. The expected reference range for calcium is 8. 5 to 10. 5 milligrams per deciliter. if the calcium level is low, the provider should be notified, and oral or intravenous calcium replacement should be administered.

a nurse is assisting a client who has hypothyroidism with meal planning. Which of the following foods should the nurse recommend that the client add to her diet?

whole grains constipation is a classic manifestation of hypothyroidism, therefore, this client should increase her fluid and fiber intake. Whole grains provide ample amounts of fiber