Exam 3 - NCLEX-RN & Med-Surg Success
MSS #12, pg. 315 The nurse is developing a care plan for the client diagnosed with type 1 DM. The nurse identifies the problem "high risk for hyperglycemia related to noncompliance with the medication regimen." Which statement is an appropriate short-term goal for the client? 1. The client will have a blood glucose level between 90 and 140 2. The client will demonstrate appropriate insulin injection techniques 3. The nurse will monitor the client's blood glucose levels 4 times a day 4. The client will maintain normal kidney function with 30-mL/hr urine output
1
MSS #14, pg. 315 The elderly client is admitted to the ICU diagnosed with severe HHS. Which collaborative intervention should the nurse include in the plan of care? 1. Infuse 0.9% normal saline IV 2. Administer intermediate-acting insulin 3. Perform blood glucometer checks daily 4. Monitor ABG results
1
MSS #17, pg. 315 The client diagnosed with type 1 DM is found lying unconscious on the floor of the bathroom. Which intervention should the nurse implement first? 1. Administer 50% dextrose (IVP) 2. Notify the HCP 3. Move the client to the ICU 4. Check the serum glucose level
1
MSS #2, pg. 578 The client is admitted into the ED with diaphoresis, pale clammy skin, and BP of 90/70. Which intervention should the nurse implement first? 1. Start an IV with an 18-gauge catheter 2. Administer dopamine IV infusion 3. Obtain ABGs 4. Insert an indwelling urinary catheter
1
MSS #3, pg. 314 The nurse administered 28 units of Humulin N, an intermediate-acting insulin, to a client diagnosed with type 1 diabetes at 1600. Which intervention should the nurse implement? 1. Ensure the client eats the bedtime snack 2. Determine how much food the client ate at lunch 3. Perform a glucometer reading at 0700 4. Offer the client protein after administering insulin
1
MSS #37, pg. 153 The charge nurse in the ICU is making client assignments. Which client should the charge nurse assign to the graduate nurse who has just finished the 3-month orientation? 1. The client with an abdominal peritoneal resection who has a colostomy 2. The client diagnosed with pneumonia who has acute respiratory distress syndrome 3. The client with a head injury developing disseminated intravascular coagulation 4. The client admitted with a gunshot wound who has an H&H of 7 and 22
1
MSS #39, pg. 154 The client admitted with full-thickness burns may be developing DIC. Which signs/symptoms would support the diagnosis of DIC? 1. Oozing blood from the IV catheter site 2. Sudden onset of chest pain and frothy sputum 3. Foul-smelling, concentrated urine 4. A reddened, inflamed central line catheter site
1
MSS #52, pg. 155 The client with O+ blood is in need of an emergency transfusion but the laboratory does not have any O+ blood available. Which potential until of blood could be given to the client? 1. The O- unit 2. The A+ unit 3. The B+ unit 4. Any Rh+ unit
1
MSS #54, pg. 155 The client undergoing knee replacement surgery has a "cell saver" apparatus attached to the knee when he arrives in the PACU. Which intervention should the nurse implement to care for this drainage system? 1. Infuse the drainage into the client when a prescribed amount fills the chamber 2. Attach an hourly drainage collection bag to the unit and discard the drainage 3. Replace the unit with a continuous passive motion (CPM) unit and start it on low 4. Have another nurse verify the unit number prior to reinfusing the blood
1
MSS #63, pg. 320 Which laboratory value should be monitored by the nurse for the client diagnosed with diabetes insipidus? 1. Serum sodium 2. Serum calcium 3. Urine glucose 4. Urine white blood cells
1
MSS #7, pg. 314 The home health nurse is completing the admission assessment for a 76-year-old client diagnosed with type 2 DM controlled with 70/30 insulin. Which intervention should be included in the plan of care? 1. Assess the client's ability to read small print 2. Monitor the client's serum prothrombin time (PT) level 3. Teach the client how to perform a A1C test daily 4. Instruct the client to check the feet weekly
1
MSS #71, pg. 321 The nurse is admitting a client diagnosed with SIADH. Which clinical manifestations should be reported to the HCP? 1. Serum sodium of 112 and a headache 2. Serum potassium of 5.0 and a heightened awareness 3. Serum calcium of 10 and tented tissue turgor 4. Serum magnesium of 1.2 and large urinary output
1
MSS #8, pg. 578 The nurse and an UAP are caring for a group of clients on a medical floor. Which action by the UAP warrants intervention by the nurse? 1. The UAP places a urine specimen in a biohazard bag in the hallway 2. The UAP uses the alcohol foam hand cleanser after removing gloves 3. The UAP puts soiled linen in a plastic bag in the client's room 4. The UAP obtains a disposable stethoscope for a client in a isolation room
1
MSS #91, pg. 324 The nurse identified a concept of metabolism for a client diagnosed with diabetes. Which antecedent would be identified as placing the clients at risk for diabetes? 1. Nutrition 2. Sensory perception 3. pH regulation 4. Medication
1
MSS #94, pg. 324 The nurse is teaching the client diagnosed with diabetes. Which should the nurse teach to limit the complications of diabetes? 1. Teach the client to keep the blood glucose under 140 2. Demonstrate how to test the urine for ketones 3. Instruct the client to apply petroleum jelly between the toes 4. Allow the client to eat meals as desired and then take insulin
1
NCLEX-RN #117, pg. 163 The nurse has received a prescription to transfuse a client with a unit of packed red blood cells. Before explaining the procedure to the client, the nurse should ask which initial question? 1. "Have you ever had a transfusion before?" 2. "Why do you think that you need the transfusion?" 3. "Have you ever gone into shock for any reason in the past?" 4. "Do you know the complications and risks of a transfusion?"
1
NCLEX-RN #122, pg. 164 The nurse has obtained a unit of blood from the blood bank and has checked the blood bag properly with another nurse. Just before beginning the transfusion, the nurse should assess which priority item? 1. Vital signs 2. Skin color 3. Urine output 4. Latest hematocrit level
1
NCLEX-RN #176, pg. 226 The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? 1. Increasing restlessness 2. A pulse of 86 bpm 3. Blood pressure of 110/70 4. Hypoactive bowel sounds in all 4 quadrants
1
NCLEX-RN #552, pg. 645 The nurse is monitoring a client newly diagnosed with DM for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? 1. Polyuria 2. Diaphoresis 3. Pedal edema 4. Decreased respiratory rate
1
NCLEX-RN #554, pg. 645 The 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 the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin." 2. "I need to increase my fluid intake." 3. "I need to monitor my blood glucose every 3-4 hours." 4. "I need to call the HCP because of these symptoms."
1
NCLEX-RN #570, pg. 663 The nurse is teaching a client how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching? 1. Withdraws the NPH insulin first 2. Withdraws the regular insulin first 3. Injects air into NPH insulin vial first 4. Injects an amount of air equal to the desired dose of insulin into each vial
1
NCLEX-RN #586, pg. 665 A client with DM visits a health care clinic. The client's diabetes mellitus previously had been well controlled with glyburide daily, but recently the fasting blood glucose level has been 180-200. Which medication, if added to the client's regimen, may have contributed to the hyperglycemia? 1. Prednisone 2. Atenolol 3. Phenelzine 4. Allopurinol
1
NCLEX-RN #574, pg. 664 The HCP prescribes exenatide for a client with type 1 DM who takes insulin. The nurse should plan to take which most appropriate intervention? 1. Withhold the medication and call the HCP questioning the prescription for the client 2. Administer the medication within 60 minutes before the morning and evening meal 3. Monitor the client for gastrointestinal side effects after administering the medication 4. Withdraw the insulin from the profiled pen into an insulin syringe to prepare for administration
1 *Exenatide is for Type 2 DM only and should not be combined with insulin
MSS #17, pg. 347 Which signs/symptoms should the nurse expect to assess in the client diagnosed with an insulinoma? 1. Nervousness, jitteriness, and diaphoresis 2. Flushed skin, dry mouth, and tented skin turgor 3. Polyuria, polydipsia, and polyphagia 4. Hypertension, tachycardia, and feeling hot
1 *Insulinoma is a tumor of the islet cells of the pancreas that produces insulin. The signs/symptoms of insulinoma are signs of hypoglycemia
NCLEX-RN #118, pg. 163 A client receiving a transfusion of packed red blood cells begins to vomit. The client's blood pressure is 90/50 mm Hg from a baseline of 125/78 mm Hg. The client's temperature is 100.8F orally from a baseline of 99.2F orally. The nurse determines that the client may be experiencing which complication of a blood transfusion? 1. Septicemia 2. Hyperkalemia 3. Circulatory overload 4. Delayed transfusion reaction
1 *Septicemia occurs with the transfusion of blood contaminated with microorganisms. Signs include chills, fever, vomiting, diarrhea, hypotension, and the development of shock. Hyperkalemia causes weakness, paresthesias, abdominal cramps, diarrhea, and dysrhythmias. Circulatory overload causes cough, dyspnea, chest pain, wheezing, tachycardia, and hypertension. A delayed transfusion reaction can occur days to years after a transfusion. Signs include fever, mild jaundice, and a decreased hematocrit level.
MSS #12, pg. 579 The nurse is caring for a client diagnosed with septic shock who has hypotension, decreased urine output, and cool, pale skin. Which case of septic shock is the client experiencing? 1. The hypodynamic phase 2. The compensatory phase 3. The hyperdynamic phase 4. The progressive phase
1 *This is the same as the refractory phase
NCLEX-RN #128, pg. 165 A client requiring surgery is anxious about the possible need for a blood transfusion during or after the procedure. The nurse suggests to the client to take which actions to reduce the risk of possible transfusion complications? Select all that apply. 1. Ask a family member to donate blood ahead of time 2. Give an autologous blood donation before the surgery 3. Take iron supplements before surgery to boost hemoglobin levels 4. Request that any donated blood be screened twice by the blood bank 5. Take adequate amounts of vitamin C several days prior to the surgery date
1, 2
NCLEX-RN #576, pg. 664 The home health care nurse is visiting a client who was recently diagnosed with type 2 DM. The client is prescribed repaglinide and metformin. The nurse should provide which instructions to the client? Select all that apply. 1. Diarrhea may occur secondary to the metformin 2. The repaglinide is not taken if a meal is skipped 3. The repaglinide is taken 30 minutes before eating 4. A simple sugar food item is carried and used to treat mild hypoglycemia episodes 5. Muscle pain is an expected effect of metformin and may be treated with acetaminophen 6. Metformin increases hepatic glucose production to prevent hypoglycemia associated with repaglinide
1, 2, 3, 4
MSS #24, pg. 316 The client is admitted to the ICU diagnosed with DKA. Which interventions should the nurse implement? Select all that apply. 1. Maintain adequate ventilation 2. Assess fluid volume status 3. Administer IV potassium 4. Check for urinary ketones 5. Monitor intake and output
1, 2, 3, 4, 5
MSS #95, pg. 324 Which interrelated concepts could be identified as actual or potential for a 56-year-old male client diagnosed with DM type 2? Select all that apply. 1. Nutrition 2. Metabolism 3. Infection 4. Male reproduction 5. Skin integrity
1, 2, 3, 4, 5
MSS #87, pg. 323 The nurse identified a concept of metabolism for a client diagnosed with DM type 1. Which interventions should the nurse include in the plan of care? Select all that apply. 1. Teach the client to perform self glucose monitoring 2. Instruct the client about complications of high-glucose levels 3. Instruct the client to inspect the feet daily 4. Explain the need to carry a source of quick-acting proteins 5. Encourage the client to have regular eye exams
1, 2, 3, 5
MSS #68, pg. 321 The nurse is planning the care of a client diagnosed with SIADH. Which interventions should be implemented? Select all that apply. 1. Restrict fluids per HCP order 2. Assess LOC every 2 hours 3. Provide an atmosphere of stimulation 4. Monitor urine and serum osmolality 5. Weigh the client every 3 days
1, 2, 4
MSS #9, pg. 315 The diabetic educator is teaching a class on diabetes type 1 and is discussing sick-day rules. Which interventions should the diabetes educator include in the discussion? Select all that apply. 1. Take diabetic medication even if unable to eat the client's normal diabetic diet 2. If unable to eat, drink liquids equal to the client's normal caloric intake 3. It is not necessary to notify the HCP if ketones are in the urine 4. Test blood glucose level and test urine ketones once a day and keep a record 5. Call the HCP if glucoses levels are higher than 180
1, 2, 5
NCLEX-RN #523, pg. 607 A client with carcinoma of the lung develops syndrome of inappropriate antidiuretic hormone (SIADH) as a complication of the cancer. The nurse anticipates that the HCP will request which prescriptions? Select all that apply. 1. Radiation 2. Chemotherapy 3. Increased fluid intake 4. Decreased oral sodium intake 5. Serum sodium level determination 6. Medication that is antagonistic to antidiuretic hormone
1, 2, 5, 6
NCLEX-RN #575, pg. 664 A client is taking Humulin NPH insulin and regular insulin every morning. The nurse should provide which instructions to the client? Select all that apply. 1. Hypoglycemia may be experienced before dinnertime 2. The insulin dose should be decreased if illness occurs 3. The insulin should be administered at room temperature 4. The insulin vial needs to be shaken vigorously to break up the precipitates 5. The NPH insulin should be drawn into the syringe first, then the regular insulin
1, 3
MSS #49, pg. 154 The client has a hematocrit of 22.3% and a hemoglobin of 7.7. The HCP has ordered two (2) units of packed red blood cells to be transfused. Which interventions should the nurse implement? Select all that apply. 1. Obtain a signed consent 2. Initiate a 22-gauge IV 3. Assess the client's lungs 4. Check for allergies 5. Hang a keep-open IV of D5W
1, 3, 4
NCLEX-RN #563, pg. 646 The nurse is monitoring a client who was diagnosed with type 1 DM and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? Select all that apply. 1. Tremors 2. Anorexia 3. Irritability 4. Nervousness 5. Hot, dry skin 6. Muscle cramps
1, 3, 4
NCLEX-RN #556, pg. 645 The nurse is admitting a client who is diagnosed with SIADH and has a serum sodium of 118. Which health care provider prescriptions should the nurse anticipate receiving? Select all that apply. 1. Initiate an infusion of 3% NaCl 2. Administer IV furosemide 3. Restrict fluids to 800 mL over 24 hours 4. Elevate the head of the bed to high Fowler's 5. Administer a vasopressin antagonist as prescribed
1, 3, 5
NCLEX-RN, #127, pg. 164 The nurse who is about to begin a blood transfusion knows that blood cells start to deteriorate after a certain period of time. The nurse takes which actions in order to prevent a complication of the blood transfusion as it relates to deterioration of blood cells? Select all that apply. 1. Checks the expiration date 2. Inspects for the presence of clots 3. Checks the blood group and type 4. Checks the blood identification number 5. Hangs the blood within the specified time frame per agency policy
1, 5
MSS #1, pg. 578 The client diagnosed with hypovolemic shock has a BP of 100/60. Fifteen minutes later the BP is 88/64. How much narrowing of the client's pulse pressure has occurred between the two readings?
16
MSS #1, pg. 314 An 18-year-old female client, 5'4" tall, weighing 113 kg, comes to the clinic for a non healing wound on her lower leg, which she has had for 2 weeks. Which disease process should the nurse suspect the client has developed? 1. Type 1 diabetes 2. Type 2 diabetes 3. Gestational diabetes 4. Acanthosis nigricans
2
MSS #11, pg. 315 The nurse at a freestanding health-care clinic is caring for a 56-year-old male client who is homeless and is a type 2 diabetic controlled with insulin. Which action is an example of client advocacy? 1. Ask the client if he has somewhere he can go and live 2. Arrange for someone to give him insulin at a local homeless shelter 3. Notify Adult Protective Services about the client's situation 4. Ask the HCP to take the client off insulin because he is homeless
2
MSS #15, pg. 315 Which electrolyte replacement should the nurse anticipate being ordered by the HCP in the client diagnosed with DKA who has just been admitted to the ICU? 1. Glucose 2. Potassium 3. Calcium 4. Sodium
2
MSS #18, pg. 316 Which assessment data indicate the client diagnosed with DKA is responding to the medical treatment? 1. The client has tented skin turgor and dry mucous membranes 2. The client is alert and oriented to date, time, and place 3. The client's ABG results are pH 7.29, PaCO2 44, and HCO3 15 4. The client's serum potassium level is 3.3
2
MSS #19, pg. 316 The UAP on the medical floor tells the nurse that the client diagnosed with DKA wants something else to eat for lunch. Which intervention should the nurse implement? 1. Instruct the UAP to get the client additional food 2. Notify the dietician about the client's request 3. Request the HCP increase the client's caloric intake 4. Tell the UAP the client cannot have anything else
2
MSS #3, pg. 346 The nurse is preparing to administer sliding-scale insulin to a client with type 2 DM. The medication administration record is as follows: At 1130, the client has a blood glucometer level of 322. Which intervention should the nurse implement? 1. Notify the HCP 2. Administer 10 units of regular insulin 3. Administer 5 units of Humalog insulin 4. Administer 10 units of intermediate-acting insulin
2
MSS #4, pg. 578 The client diagnosed with septicemia has the following HCP orders. Which HCP order has the highest priority? 1. Provide clear liquid diet 2. Initiate IV antibiotic therapy 3. Obtain a STAT chest x-ray 4. Perform hourly glucometer checks
2
MSS #40, pg. 154 Which laboratory result would the nurse expect in the client diagnosed with DIC? 1. A decreased prothrombin time 2. A low fibrinogen level 3. An increased platelet count 4. In increased white blood cell count
2
MSS #50, pg. 155 The client is admitted to the ED after a motor-vehicle accident. The nurse notes profuse bleeding from a right-sided abdominal injury. Which intervention should the nurse implement first? 1. Type and crossmatch for red blood cells immediately (STAT) 2. Initiate an IV with an 18-gauge needle and hang normal saline 3. Have the client sign a consent for an exploratory laparotomy 4. Notify the significant other of the client's admission
2
MSS #55, pg. 155 Which statement is the scientific rationale for infusing a unit of blood in less than 4 hours? 1. The blood will coagulate if left out of the refrigerator for greater than 4 hours. 2. The blood has the potential for bacterial growth if allowed to infuse longer 3. The blood components begin to break down after 4 hours 4. The blood will not be affected; this is a laboratory procedure
2
MSS #61, pg. 320 The client diagnosed with a pituitary tumor developed SIADH. Which interventions should the nurse implement? 1. Assess for dehydration and monitor blood glucose levels 2. Assess for nausea and vomiting and weigh daily 3. Monitor potassium levels and encourage fluid intake 4. Administer vasopressin IV and conduct a fluid deprivation test
2
MSS #64, pg. 320 The nurse is discharging a client diagnosed with diabetes insipidus. Which statement made by the client warrants further intervention? 1. "I will keep a list of my medications in my wallet and wear a Medic Alert bracelet." 2. "I should take my medication in the morning and leave it refrigerated at home." 3. "I should weigh myself every morning and record any weight gain." 4. "If I develop a tightness in my chest, I will call my HCP."
2
MSS #8, pg. 314 The client with type 2 DM controlled with biguanide oral diabetic medication is scheduled for a CT scan with contrast of the abdomen to evaluate pancreatic function. Which intervention should the nurse implement? 1. Provide a high-fat diet 24 hours prior to the test 2. Hold the biguanide medication for 48 hours prior to the test 3. Obtain an informed consent form for the test 4. Administer pancreatic enzymes prior to the test
2
MSS #85, pg. 322 The nurse is administering morning medications. Which medications should the nurse question? 1. The oral carafate to a client who has not even breakfast 2. The subcutaneous insulin to a client refusing blood glucose checks 3. The levothyroxine PO to a client diagnosed with hypothyroidism 4. The sliding scale insulin to a client whose blood glucose level is 320
2
MSS #9, pg. 578 The elderly female client with vertebral fractures who has been self-medicting with ibuprofen, a nonsteroidal anti-inflammatory dry (NSAID), presents to the ED complaining of abdominal pain, is pale and clammy, and has a P of 110 and a NP of 92/60. Which type of shock should the nurse suspect? 1. Cardiogenic shock 2. Hypovolemic shock 3. Neurogenic shock 4. Septic shock
2
NCLEX-RN #130, pg. 165 A client has a prescription to receive a unit of packed red blood cells. The nurse should obtain which IV solution from the IV storage area to hang with the blood product at the client's bedside? 1. Lactated Ringer's 2. 0.9% sodium chloride 3. 5% dextrose in 0.9% sodium chloride 4. 5% dextrose in 0.45% sodium chloride
2
NCLEX-RN #175, pg. 226 The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? 1. Red, hard skin 2. Serous drainage 3. Purulent drainage 4. Warm, tender skin
2
NCLEX-RN #308, pg. 368 The nurse is monitoring a client in the immediate postpartum period for signs of hemorrhage. Which sign, if noted, would be an early sign of excessive blood loss? 1. A temperature of 100.4F 2. An increase in the pulse rate from 88 to 102 bpm 3. A blood pressure change from 130/88 to 124/80 4. An increase in the respiratory rate from 18 to 22 bpm
2
NCLEX-RN #549, pg. 645 A client with DM demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? 1. Administer a sedative 2. Convey empathy, trust, and respect toward the client 3. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear 4. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening
2
NCLEX-RN #553, pg. 645 The nurse is preparing a plan of care for a client with DM who has hyperglycemia. The nurse places priority on which client problem? 1. Lack of knowledge 2. Inadequate fluid volume 3. Compromised family coping 4. Inadequate consumption of nutrients
2
NCLEX-RN #559, pg. 646 A client with type 1 DM calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? 1. "I should not exercise since I am taking insulin." 2. "The best time for me to exercise is after breakfast." 3. "The best time for me to exercise is mid- to late afternoon." 4. "NPH is a basal insulin, so I should exercise in the evening."
2
NCLEX-RN #571, pg. 663 The home care nurse visits a client recently diagnosed with DM who is taking Humulin NPH insulin daily. The client asks the nurse how to store the unopened vials of insulin. The nurse should tell the client to take which action? 1. Freeze the insulin 2. Refrigerate the insulin 3. Store the insulin a dark, dry place 4. Keep the insulin at room temperature
2
NCLEX-RN #573, pg. 663 The nurse is providing discharge teaching for a client newly diagnosed with type 2 DM who has been prescribed metformin. Which client statement indicates the need for further teaching? 1. "It is okay if I skip meals now and then." 2. "I need to constantly watch for signs of low blood sugar." 3. "I need to let my HCP know if I get unusually tired." 4. "I will be sure to not drink alcohol excessively while on this medication."
2
NCLEX-RN #582, pg. 664 The nurse is providing instructions to the client newly diagnosed with DM who has been prescribed pramlintide. Which instruction should the nurse include in the discharge teaching? 1. "Inject the pramlintide at the same time you take your other medications." 2. "Take your prescribed pills 1 hour before or 2 hours after the injection." 3. "Be sure to take the pramlintide with food so you don't upset your stomach." 4. "Make sure you take your pramlintide immediately after you eat so you don't experience a low blood sugar."
2
MSS #5, pg. 578 The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client? 1. Cool, moist skin 2. Bradycardia 3. Wheezing 4. Decreased bowel sounds
2 *Neurogenic shock = dry, warm skin, & bradycardia
NCLEX-RN #124, pg. 164 Following infusion of a unit of packed red blood cells, the client has developed new onset of tachycardia, bounding pulses, crackles, and wheezes. Which action should the nurse implement first? 1. Maintain bed rest with legs elevated 2. Place the client in high-Fowler's position 3. Increase the rate of infusion of intravenous fluids 4. Consult with the HCP regarding initiation of oxygen therapy
2 *These are signs of fluid overload.
MSS #67, pg. 321 The HCP has ordered 40 g/24 hr of intranasal vasopressin for a client diagnosed with diabetes insipidus. Each metered spray delivers 10 g. The client takes the medication every 12 hours. How many sprays are delivered at each dosing time?
2 sprays
NCLEX-RN #547, pg. 645 A client with a diagnosis of DKA is being treated in the ED. Which findings support this diagnosis? Select all that apply. 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level
2, 3, 5
NCLEX-RN #548, pg. 645 The nurse teaches a client with DM about differentiating between hypoglycemia and keto acidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor
2, 3, 5
NCLEX-RN #572, pg. 663 Glimepiride is prescribed for a client with DM. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply. 1. Alcohol 2. Red meats 3. Whole-grain cereals 4. Low-calorie desserts 5. Carbonated beverages
2, 3, 5
MSS #26, pg. 181 The nurse is administering a transfusion of PRBCs to a client. Which intervention should the nurse implement? List in order of performance. 1. Start the transfusion slowly 2. Have the client sign a permit 3. Assess the IV site for size and patency 4. Check the blood with another nurse at the bedside 5. Obtain the blood from the laboratory
2, 3, 5, 4, 1
NCLEX-RN #583, pg. 665 The nurse teaches the client, who is newly diagnosed with diabetes insipidus, about the prescribed intranasal desmopressin. Which statements by the client indicate understanding? Select all that apply. 1. "This medication will turn my urine orange." 2. "I should decrease my oral fluids when I start this medication." 3. "The amount of urine I make should increase if this medicine is working." 4. "I need to follow a low-fat diet to avoid pancreatitis when taking this medicine." 5. "I should report headache and drowsiness to my HCP since these symptoms could be related to my desmopressin."
2, 5
MSS #10, pg. 315 The client received 10 unites of Humulin R, a fast-acting insulin, at 0700. At 1030, the UAP tells the nurse the client has a headache and is really acting "funny." Which intervention should the nurse implement first? 1. Instruct the UAP to obtain the blood glucose level 2. Have the client drink 8 ounces of orange juice 3. Go to the client's room and assess the client for hypoglycemia 4. Prepare to administer 1 ampule 50% dextrose IV
3
MSS #10, pg. 578 The client has recently experienced a myocardial infarction. Which action by the nurse helps prevent cariogenic shock? 1. Monitor the client's telemetry 2. Turn the client every 2 hours 3. Administer oxygen via nasal cannula 4. Place the client in the Trendelenburg position
3
MSS #13, pg. 315 The client diagnosed with type 2 DM is admitted to the ICU with HHS coma. Which assessment data should the nurse expect the client to exhibit? 1. Kussmaul's respirations 2. Diarrhea and epigastric pain 3. Dry mucous membranes 4. Ketone breath odor
3
MSS #2, pg. 314 The client diagnosed with type 1 diabetes has a A1C of 8.1%. Which interpretation should the nurse make based on this result? 1. This result is below normal levels 2. This result is within acceptable levels 3. This result is above recommended levels 4. This result is dangerously high
3
MSS #2, pg. 346 The nurse is teaching the client diagnosed with type 2 DM about diet. Which diet selection indicates the client understands the teaching? 1. A submarine sandwich, potato chips, and diet cola 2. 4 slices of a supreme thin-crust pizza and milk 3. Smoked turkey sandwich, celery sticks, and unsweetened tea 4. A roast beef sandwich, fried onion rings, and a cola
3
MSS #20, pg. 316 The ED nurse is caring for a client diagnosed with HHS who has a blood glucose of 680. Which question should the nurse ask the client to determine the cause of this acute complication? 1. "When is the last time you took your insulin?" 2. "When did you have your last meal?" 3. "Have you had some type of infection lately?" 4. "How long have you had diabetes?"
3
MSS #21, pg. 316 The nurse is discussing ways to prevent DKA with the client diagnosed with type 1 DM. Which instruction is most important to discuss with the client? 1. Refer the client to the American Diabetes Association 2. Do not take any OTC medications 3. Take the prescribed insulin even when unable to eat because of illness 4. Explain the need to get the annual flu and pneumonia vaccines
3
MSS #22, pg. 316 The charge nurse is making client assignments in the ICU. Which client should be assigned to the most experienced nurse? 1. The client with type 2 DM who has a blood glucose of 348 2. The client diagnosed with type 1 DM who is experiencing hypoglycemia 3. The client with DKA who has multifocal premature ventricular contractions 4. The client with HHS who has a plasma osmolarity of 290
3
MSS #3, pg. 578 The nurse is caring for a client diagnosed with septic shock. Which assessment data warrant immediate intervention by the nurse? 1. Vital signs T 100.4F, P 104, R 26, and BP 102/60 2. A white blood cell count of 18,000 3. A urinary output of 90 mL in the last 4 hours 4. The client complains of being thirsty
3
MSS #41, pg. 154 Which collaborative treatment would the nurse anticipate for the client diagnosed with DIC? 1. Administer oral anticoagulants 2. Prepare for plasmapheresis 3. Administer frozen plasma 4. Calculate the intake and output
3
MSS #51, pg. 155 The nurse is working in a blood bank facility procuring units of blood from donors. Which client would not be a candidate to donate blood? 1. The client who had wisdom teeth removed a week ago 2. The nursing student who received a measles immunization 2 months ago 3. The mother with a 6-week-old newborn 4. The client who developed an allergy to aspirin in childhood
3
MSS #56, pg. 155 The HCP orders 2 units of blood to be administered over 8 hours each for a client diagnosed with heart failure. Which intervention(s) should the nurse implement? 1. Call the HCP to question the order because blood must infuse within 4 hours 2. Retrieve the blood from the laboratory and run each unit at an 8-hour rate 3. Notify the laboratory to split each unit into half-units and infuse each half for 4 hours 4. Infuse each unit for 4 hours, the maximum rate for a unit of blood
3
MSS #59, pg. 156 The nurse is caring for clients on a medical floor. After the shift report, which client should be assessed first? 1. The client who is 2/3 of the way through a blood transfusion and has had no complaints of dyspnea or hives 2. The client diagnosed with leukemia who has a hematocrit of 18% and petechiae covering the body 3. The client with peptic ulcer disease who called over the intercom to say that he is vomiting blood 4. The client diagnosed with Crohn's disease who is complaining of perineal discomfort
3
MSS #6, pg. 314 The nurse is assessing the feet of a client with long-term type 2 DM. Which assessment data warrant immediate intervention by the nurse? 1. The client has crumbling toenails 2. The client has athlete's foot 3. The client has a necrotic big toe 4. The client has thickened toenails
3
MSS #6, pg. 578 The nurse in the ED administered an intramuscular antibiotic in the left gluteal muscle to the client with pneumonia who is being discharged home. Which intervention should the nurse implement? 1. Ask the client about drug allergies 2. Obtain a sterile sputum specimen 3. Have the client wait for 30 minutes 4. Place a warm washcloth on the client's left hip
3
MSS #65, pg. 320 The client is admitted to the medical unit with a diagnosis of rule-out diabetes insipidus. Which instructions should the nurse teach regarding a fluid deprivation test? 1. The client will be asked to drink 100 mL of fluid as rapidly as possible and then will not be allowed fluid for 24 hours 2. The client will be administered an injection of ADH and urine output will be measured for 4 to 6 hours 3. The client will have nothing by mouth (NPO), and vital signs and weights will be done hourly until the end of the test 4. An IV will be started with normal saline, and the client will be asked to ty to hold the urine in the bladder until a sonogram can be done
3
MSS #66, pg. 320 The nurse is caring for clients on a medical floor. Which client should be assessed first? 1. The client diagnosed with SIADH who has a weight gain of 1.5 pounds since yesterday 2. The client diagnosed with a pituitary tumor who has developed diabetes insipidus and has an intake 1,500 mL and an output of 1,600 mL in the last 8 hours 3. The client diagnosed with SIADH who is having muscle twitching 4. The client diagnosed with diabetes insipidus who is complaining of feeling tired after having to get up at night
3
MSS #72, pg. 321 The male client diagnosed with SIADH secondary to cancer of the lung tells the nurse he wants to discontinue the fluid restriction and does not care if he dies. Which action by the nurse is an example of the ethical principle of autonomy? 1. Discuss the information the client told the nurse with the HCP and significant other 2. Explain it is possible the client could have a seizure if he drank fluid beyond the restrictions 3. Notify the HCP of the client's wishes and give the client fluids as desired 4. Allow the client an extra drink of water and explain the nurse could get into trouble if the client tells the HCP
3
MSS #93, pg. 324 The client diagnosed with diabetes complains of a curtain being drawn across the eyes. Which should the nurse implement first? 1. Asses the eyes using an ophthalmoscope 2. Tell the client to keep the eyes closed 3. Notify the HCP 4. Call the Rapid Response Team
3
NCLEX-RN #116, pg. 163 Packed red blood cells have been prescribed for a female client with a hemoglobin level of 7.6 and a hematocrit level of 30%. The nurse takes the client's temperature before hanging the blood transfusion and records 100.6F orally. Which action should the nurse take? 1. Begin the transfusion as prescribed 2. Administer an antihistamine and begin the transfusion 3. Delay hanging the blood and notify the health care provider 4. Administer 2 tablets of acetaminophen and begin the transfusion
3
NCLEX-RN #119, pg. 16 The nurse determines that a client is having a transfusion reaction. After the nurse stops the transfusion, which action should be taken next? 1. Remove the IV line 2. Run a solution of 5% dextrose in water 3. Run normal saline at a keep-vein-open rate 4. Obtain a culture of the tip of the catheter device removed from the client
3
NCLEX-RN #126, pg. 164 A client is brought to the ED having experienced blood loss related to an arterial laceration. Which blood component should the nurse expect the HCP to prescribe? 1. Platelets 2. Granulocytes 3. Fresh-frozen plasma 4. Packed red blood cells
3
NCLEX-RN #131, pg. 165 The nurse is caring for a client who is receiving a blood transfusion and is complaining of a cough. The nurse checks the client's vital signs, which include temperature of 97.2F, pulse of 108 bpm, blood pressure of 152/76 mm Hg, respiratory rate of 24 bpm, and an oxygen saturation level of 95% on room air. The client denies pain at this time. Based on this information, what initial action should the nurse take? 1. Collect a urine sample for analysis 2. Place the client in an upright position 3. Compare current data to baseline data 4. Slow the rate of the blood transfusion
3
NCLEX-RN #314, pg. 368 The nurse is preparing to care for four assigned clients. Which client is at most risk for hemorrhage? 1. A primiparous client who delivered 4 hours ago 2. A multiparous client who delivered 6 hours ago 3. A multiparous client who delivered a large baby after oxytocin induction 4. A primiparous client who delivered 6 hours ago and had epidural anesthesia
3
NCLEX-RN #545, pg. 644 A client is brought to the ED in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. IV infusion of normal saline 4. IV infusion of sodium bicarbonate
3
NCLEX-RN #551, pg. 645 A client is admitted to a hospital with a diagnosis of DKA. The initial blood glucose level is 950. A continuous IV infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240. The nurse would next prepare to administer which medication? 1. An ampule of 50% dextrose 2. NPH insulin subcutaneously 3. IV fluids containing dextrose 4. Phenytoin for the prevention of seizures
3
NCLEX-RN #566, pg. 646 The nurse performs a physical assessment on a client with type 2 DM. Findings include a fasting blood glucose level of 120, temperature of 101F, pulse of 102 bpm, respirations of 22 bpm, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? 1. Pulse 2. Respiration 3. Temperature 4. Blood pressure
3
MSS #4, pg. 314 The client diagnosed with type 1 diabetes is receiving Humalog, a rapid-acting insulin, by sliding scale. The order reads blood glucose level: <150, 0 units; 151 - 200, 3 units; 201 - 250, 6 units; >250, contact HCP The UAP reports to the nurse the client's glucometer reads is 189. How much insulin should be administered to the client?
3 units
MSS #1, pg. 346 The nurse is teaching a community class to people with type 2 DM. Which explanation explains the development of type 2 DM? 1. The islet cells in the pancreas stop producing insulin 2. The client eats too many foods high sugar 3. The pituitary gland does not produce vasopressin 4. The cells become resistant to the circulating insulin
4
MSS #11, pg. 578 The client diagnosed with septicemia is receiving a broad-spectrum antibiotic. Which laboratory data require the nurse to notify the HCP? 1. The client's potassium level is 3.8 2. The urine culture indicates high sensitivity to the antibiotic 3. The client's pulse oximeter reading is 94% 4. The culture and sensitivity is resistant to the client's antibiotic
4
MSS #16, pg. 315 The client diagnosed with HHS was admitted yesterday with a blood glucose level of 780. The client's blood glucose level is now 300. Which intervention should the nurse implement? 1. Increase the regular insulin IV drip 2. Check the client's urine for ketones 3. Provide the client with a therapeutic diabetic meal 4. Notify the HCP to obtain an order to decrease insulin
4
MSS #22, pg. 181 The nurse writes a diagnosis of "potential for fluid volume deficit related to bleeding" for a client diagnosed with DIC. Which would be an appropriate goal for this client? 1. The client's clot formation will resolve in 2 days 2. The saturation of the client's dressings will be documented 3. The client will use lemon-glycerin swabs for oral care 4. The client's urine output will be greater than 30 mL/hour
4
MSS #23, pg. 316 Which ABG results should the nurse expect in the client diagnosed with DKA? 1. pH 7.34, PaO2 99, PaCO2 48, HCO3 24 2. pH 7.38, PaO2 95, PaCO2 40, HCO3 22 3. pH 7.46, PaO2 85, PaCO2 30, HCO3 26 4. pH 7.30, PaO2 90, PaCO2 30, HCO3 18
4
MSS #24, pg. 181 Fifteen minutes after the nurse has initiated a transfusion of PRBCs, the client becomes restless and complains of itching on the trunk and arms. Which intervention should the nurse implement first? 1. Collect urine for analysis 2. Notify the laboratory of the reaction 3. Administer diphenhydramine, an antihistamine 4. Stop the transfusion at the hub
4
MSS #24, pg. 348 Which sign/symptom should the nurse expect in the client diagnosed with SIADH? 1. Excessive thirst 2. Orthopnea 3. Ascites 4. Concentrated urine output
4
MSS #38, pg. 154 Which client would be most at risk for developing DIC? 1. A 35-year-old pregnant client with placenta previa 2. A 42-year-old client with a pulmonary embolus 3. A 60-year-old client receiving hemodialysis 3 days a week 4. A 78-year-old client diagnosed with septicemia
4
MSS #5, pg. 314 The nurse is discussing the importance of exercising with a client diagnosed with type 2 DM whose diabetes is well controlled with diet and exercise. Which information should the nurse include in the teaching about diabetes? 1. Eat a simple carbohydrate snack before exercising 2. Carry peanut butter crackers when exercising 3. Encourage the client to walk 20 minutes, 3 times a week 4. Perform warm-up and cool-down exercises
4
MSS #53, pg. 155 The client is scheduled to have a total hip replacement in 2 months and has chosen to prepare for autologous transfusions. Which medication would the nurse administer to prepare the client? 1. Prednisone, a glucocorticoid 2. Zithromax, an antibiotic 3. Ativan, a tranquilizer 4. Epogen, a biologic response modifier
4
MSS #57, pg. 155 The client receiving a unit of PRBCs begins to chill and develop hives. Which action should be the nurse's first response? 1. Notify the laboratory and HCP 2. Administer the histamine-1 blocker, Benadryl, IV 3. Assess the client for further complications 4. Stop the transfusion and change the tubing at the hub
4
MSS #58, pg. 155 The nurse and a UAP are caring for clients on an oncology floor. Which nursing task would be delegated to the UAP? 1. Assess the urine output on a client who has had a blood transfusion reaction 2. Take the first 15 minutes of vital signs on a client receiving a unit of PRBCs 3. Auscultate the lung sounds of a client prior to a transfusion 4. Assist a client who received 10 units of platelets in brushing the teeth
4
MSS #69, pg. 321 The nurse is caring for a client diagnosed with diabetes insipidus. Which intervention should be implemented? 1. Administer sliding-scale insulin as ordered 2. Restrict caffeinated beverages 3. Check urine ketones if blood glucose is >250 4. Assess tissue turgor every 4 hours
4
MSS #7, pg. 578 The nurse caring for a client with sepsis writes the client diagnosis of "alterations in comfort R/T chills and fever." Which intervention should be included in the plan of care? 1. Ambulate the client in the hallway every shift 2. Monitor urinalysis, creatinine level, and BUN level 3. Apply sequential compression devices to the lower extremities 4. Administer an antipyretic medication every 4 hours PRN
4
MSS #89, pg. 323 The concepts of nutrition and metabolism have been identified for the client. Which referral should the nurse include in the plan of care? 1. Physical therapy 2. Social work 3. Speech therapy 4. Dietary
4
MSS #96, pg. 324 Which client would the nurse identify as being at risk for developing diabetes? 1. The client who eats mostly candy and potatoes 2. The 22-year-old client who has been taking birth control pills 3. The client who has a cousin who has had diabetes for 2 years 4. The 38-year-old female who delivered a 10-pound infant
4
NCLEX-RN #121, pg. 164 A client has received a transfusion of platelets. The nurse evaluates that the client is benefiting most from this therapy if the client exhibits which finding? 1. Increased hematocrit level 2. Increased hemoglobin level 3. Decline of elevated temperature to normal 4. Decreased oozing of blood from puncture sites and gums
4
NCLEX-RN #123, pg. 164 The nurse has just received a prescription to transfuse a unit of packed red blood cells for an assigned client. What action should the nurse take next? 1. Check a set of vital signs 2. Order the blood from the blood bank 3. Obtain a Y-site blood administration tubing 4. Check to be sure that consent for the transfusion has been signed
4
NCLEX-RN #125, pg. 164 The nurse, listening to the morning report, learns that an assigned client received a unit of granulocytes the previous evening. The nurse makes a note to assess the results of which daily serum laboratory studies to assess the effectiveness of the transfusion? 1. Hematocrit level 2. Erythrocyte count 3. Hemoglobin level 4. White blood cell count
4
NCLEX-RN #546, pg. 644 An external insulin pump is prescribed for a client with DM. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? 1. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. 2. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. 3. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. 4. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus does from the pump before each meal.
4
NCLEX-RN #550, pg. 645 The nurse provides instructions to a client newly diagnosed with type 1 DM. The nurse recognizes accurate understanding of measures to prevent DKA when the client makes which statement? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my HCP if my blood glucose level is higher than 250."
4
NCLEX-RN #558, pg. 646 The nurse is caring for a client admitted to the ED with DKA. In the acute phase, the nurse plans for which priority intervention? 1. Correct the acidosis 2. Administer 5% dextrose IV 3. Apply a monitor for an electrocardiogram 4. Administer short-duration insulin IV
4
NCLEX-RN #129, pg. 165 A client with severe blood loss resulting from multiple trauma requires rapid transfusion of several units of blood. The nurse asks another health team member to obtain which divide for use during the transfusion procedure to help reduce the risk of cardiac dysrhythmias? 1. Infusion pump 2. Pulse oximeter 3. Cardiac monitor 4. Blood-warming device
4 *Rapid transfusions of cool blood places the client at risk for cardiac dysrhythmias.
MSS #26, pg. 348 The client diagnosed with type 1 DM received regular insulin 2 hours ago. The client is complaining of being jittery and nervous. Which interventions should the nurse implement? List in order of priority. 1. Call the laboratory to confirm blood glucose levels 2. Administer a quick-acting carbohydrate 3. Have the client eat a bologna sandwich 4. Check the client's blood glucose level at the bedside 5. Determine if the client has had anything to eat.
5, 2, 4, 1, 3
MSS #60, pg. 156 The client received 2 units of PRBCs of 250 mL with 63 mL of preservative each during the shift. There was 240 mL of saline remaining in the 500-mL bag when the nurse discarded the blood tubing. How many milliliters of fluid should be documented on the intake and output record?
886 mL
