Management Quiz 2
The plan of care for a patient with diabetes includes all of these interventions. which intervention should the nurse delegate to UAP?
1. reminding the patient to put on well-fitting shoes before ambulating.
The nurse is providing care for a client newly diagnosed with early Alzheimer disease (AD). On assessment, which finding would the nurse expect to discover?
1. short term memory impairment
The nurse is caring for a 25 year old patient admitted to the acute care unit with an extra strong thirst, and dilute, excessive straw colored urine output (up to 15L/day). What does the nurse suspect?
Diabetes insipidus (DI)
A client who has Alzheimer disease is hospitalized with new-onset angina. Her spouse tells the nurse that he does not sleep well because he needs to be sure the client does not wander during the night. He insists on checking each of the medications the nurse gives the client to be sure they are "the same pills she takes at home." Based on this information, which nursing problem is most appropriate for this client?
2. care provider role stress.
The UAP reports to the RN that a patient with type 1 Diabetes has a questions about exercise. What important points would the RN be sure to teach this patient? select all that apply.
1. exercise guidelines are based on blood glucose and urine ketone levels 3. you can exercise vigorously If you blood glucose is between 100 and 250 mg/dL (5.6 mmol/L) 5. A 5 to 10 minute warm-up and cool-down period should be included in your exercise. 6. for unplanned exercise, increased intake of carbohydrates is usually needed.
In the care of a patient with type 2 diabetes, which actions should the nurse delegate to the UAP? select all that apply.
1 providing patient with extra packets of artificial sweetener for coffee. 3. recording the liquid intake from the patient's breakfast tray. 5. checking and recording the patient's blood pressure 6. assisting the patient to ambulate to the bathroom.
A 58 year old patient with type 2 diabetes was admitted to the acute care unit with a diagnosis of chronic obstructive pulmonary disease (COPD) exacerbation. When the RN prepares a care plan for this patient, what would he or she be sure to include? Select all that apply.
1. fingerstick blood glucose checks before meals and at bedtime. 2. sliding scale insulin dosing as prescribed. 5. demonstration of the components of foot care 6. discussing the relationship between illness and glucose levels.
An LPN is assigned to administer rapid-acting insulin, lispro, to a patient with type 1 diabetes. What essential information would the RN be sure to tell the LPN?
1. give this insulin when the food tray has been delivered and the patient is ready to eat.
The nurse is caring for an 81 year old adult with type 2 diabetes, HTN, and peripheral vascular disease. Which admission assessment findings increase the patient's risk for development of hyperglycemic-hyperosmolar syndrome (HHS)? select all that apply.
1. hydrochlorothiazide (HCTZ) prescribed to control her blood pressure 3. avoids consuming liquids in the evening. 6. glucose greater than 600 mg/dL
The nurse is caring for a patient with syndrome of inappropriate antidiuretic hormone secretion (SIADH). which patient care actions should the nurse delegate to the experienced UAP? Select all that apply.
1. monitor and record strict intake and output 3. remind the patient about his or her fluid restriction 4. weigh the patient every morning using the same scale. 5. Report a weight gain of 2.2 lbs to the nurse
A 23-year-old client with a recent history of encephalitis is admitted to the medical unit with new-onset generalized tonic-clonic seizures. Which nursing activities included in the client's care will be best to assign to an LPN whom the nurse is supervising? select all that apply.
1. observing and documenting the onset and duration of any seizure activity 2. administering phenytoin 200 mg PO three times a day. 6. Turning the client to his or her side to avoid aspiration
A patient with newly diagnosed diabetes has peripheral neuropathy. Which key points should the nurse include in the teaching plan for this patient? Select all that apply.
1. "Clean and inspect your feet every day." 2. "Be sure that your shoes fit properly." 5. "Report any nonhealing skin breaks to your health care provider HCP." 6. "Use a thermometer to check the temperature of water before taking a bath."
The nurse is preparing to discharge a client with chronic low back pain. which statement by the client indicates the need for additional teaching?
1. "I will avoid exercise because the pain gets worse."
The RUN is orientating a new graduate nurse who is providing diabetes education for a patient about insulin injection. For which teaching statement by the new nurse must the RN intervene?
1. "To prevent lipohypertrophy, be sure to rotate injection sites from the abdomen to the thighs."
A client who had a stroke needs to be fed. What instruction should the nurse give to the UAP who will feed the client?
1. position the client sitting up in bed before he or she is fed.
The nurse is caring for a patient who has just undergone hypophysectomy for hyperpituitarism. Which postoperative finding requires immediate intervention?
1. presence of glucose in the nasal drainage.
Which change in vital signs would the nurse instruct the UAP to report immediately for a patient with hyperthyroidism?
1. rapid heart rate.
Which actions should the nurse delegate to an experienced UAP when caring for a client with a thrombotic stroke who has residual left sided weakness? Select all that apply.
1. Assisting the client to reposition every 2 hours 2. Reapplying pneumatic compression boots 3. Reminding the client to perform active range of motion exercises 5. setting up meal trays and assisting with feeding 6. Using a lift to assist the client up to a bedside chair.
A client with a cervical spinal cord injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may assign which actions to the LPN? Select all that apply.
1. Checking the client's skin for pressure from the device. 3. Observing the halo insertion sites for signs of infection. 4. Cleaning the halo insertion sites with hydrogen peroxide 6. Administering oral medications as ordered.
A client with multiple sclerosis tells the UAP after physical therapy that she is too tired to take a bath. What is the priority nursing concern at this time?
1. Fatigue
The RN supervising a senior nursing student who is caring for a client with a right hemisphere stroke. Which action by the student nurse requires that the RN intervene?
1. Instructing the client to sit up straight and the client responds with a puzzled expression.
What is the priority nursing concern for a client experiencing a migraine headache?
1. Pain
A female patient is admitted with diagnosis of primary hypofunction of the adrenal glands. Which nursing assessment finding supports this diagnosis?
1. Patchy areas of pigment loss over the face.
The nurse is preparing to discharge a patient with hypopituitarism caused by a benign pituitary tumor, who is prescribed the drug bromocriptine. Which key points would the nurse teach the patient about this drug? Select all that apply.
1. Take this drug with a meal or snack to avoid gastrointestinal upset 3. seek medical care if you experience chest pain or dizziness while taking this drug. 4. If the drug causes headaches, you can take over-the-counter acetaminophen. 6. The purpose of bromocriptine is to shrink your pituitary to normal size
The nurse is preparing a teaching plan for a patient with type 2 diabetes who has been prescribed albiglutide. Which key points would the nurse include? Select all that apply.
1. The drug works in the intestine in response to food intake and acts with insulin for glucose regulation 3. This drug is used with diet and exercise to improve glycemic control in adults with type 2 diabetes. 5. albiglutide is administered by the subcutaneous route once a week.
Which nursing action will be implemented first if a client has a generalized tonic-clonic seizure?
1. Turn the client to one side.
The nurse on the neurologic acute care unit is assessing the orientation of a client with severe headaches. Which question would the nurse use to determine orientation? Select all that Apply.
1. When did you first experience the headache symptoms? 3. What is your health care provider's name? 4. What year and month is it? 6. What is the name of this health care facility?
The nurse is caring for a patient with diabetes who is developing diabetic ketoacidosis (DKA). which task delegation or assignment is most appropriate?
1. ask the unit clerk to page the health care provider to come to the unit.
The nurse is caring for an older patient with type 2 diabetes and diabetic retinopathy. What is the nurse's priority concern for assessing this patient?
1. assess ability to measure and inject insulin and to monitor blood glucose levels
Which actions should the nurse assign to the experienced LPN for the care of a patient with hypothyroidism? select all that apply.
1. assessing and recording the rate and depth of respirations 2. auscultating lung sounds every 4 hours. 5. checking blood pressure, heart rate, and respirations every 4 hours. 6. Reminding the patient to report any episodes of chest pain or discomfort.
The nurse is providing care for a patient who underwent thyroidectomy 2 days ago. which laboratory value requires close monitoring by the nurse?
1. calcium level
The nurse is in charge of developing a standard plan of care for an Alzheimer disease care facility and is responsible for assigning and supervising resident care given by LPNs and delegating and supervising care given by UAP. Which activity is best to assign to the LPN team leaders?
1. checking for improvement in resident memory after medication therapy is initiated.
When providing care for a patient with Addison disease, the nurse should be alert for which lab value change?
1. decreased hematocrit.
The nurse is mentoring a student nurse in the intensive care unit while caring for a client with meningococcal meningitis. Which action by the student nurse requires that the nurse intervene most rapidly?
1. entering the room without putting on a protective mask and gown
A patient with adrenal insufficiency is to be discharged and will take prednisone 10 mg orally each day. Which instruction would the nurse be sure to teach the patient?
1. excessive weight gain or swelling should be reported to the health care provider.
The RN is caring for patient with diabetes admitted with hypoglycemia that occured at home. Which teaching points for treatment of hypoglycemia at home would the nurse include in a teaching plan for the patient and family before discharge? Select all that apply.
1. signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60mg/dL 4. repeat the carbohydrate treatment if the symptoms do not resolve. 5. eat a small snack of carbohydrate and protein if the next meal is more than an hour away. 6. if the patient has severe hypoglycemia, does not respond to treatment, and is unconscious, transport to the ED.
The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? Select all that apply.
1. stroking the client's inner thigh 2. Pulling on the client's pubic hair 4. pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle
The nurse is caring for a patient with hyperthyroidism who had a partial thyroidectomy yesterday. Which change in assessment would the nurse report to the health care provider immediately?
1. temperature elevation to 100.2 F
The nurse is caring for a client with a glioblastoma who is receiving dexamethasone 4 mg IB push every 6 hours to relieve symptoms of right arm weakness and headache. which assessment information concerns the nurse the most?
1. the client no longer recognizes family members.
Which actions prescribed by the health care provider for the patient with addison disease should the nurse delegate to the experienced UAP? select all that apply.
1. weigh the patient every morning. 2. obtain fingerstick glucose before each meal and at bedtime. 3. Check vital signs every 2 hours 6. Record intake and output.
The nurse is creating a teaching plan for a client with newly diagnosed migraine headaches. Which key items will be included in the teaching plan? Select all that apply.
1.Foods that contain tyramine, such as alcohol and aged cheese, should be avoided 2. Drugs such as nitroglycerin and nifedipine should be avoided. 3. Abortive therapy is aimed at eliminating the pain during the aura. 4. A potential side effect of medications is rebound headache 5. Complementary therapies such as biofeedback and relaxation may be helpful
All of the following nursing care activities are included on the care plan for a 78 year-old man with Parkinson disease who has been referred to the home health agency. Which activities will the nurse delegate to the UAP? Select all that apply.
135 1. checking for orthostatic changes in pulse and blood pressure 3. reminding the client to allow adequate time for meals 5. assisting the client with prescribed strengthening exercises.
A patient with diabetes ha hot, dry skin; rapid and deep respirations; and a fruity odor to his breath. The charge nurse observes a newly graduated RN performing all of the following patient tasks Which actions requires that the charge nurse intervene immediately?
2. encouraging the patient to drink orange juice.
The nurse is preparing to admit a client with seizure disorder. which action can be assigned to an LPN?
2 Setting up oxygen and suction equipment
The LPN who is assigned to care for a patient with Cushing disease asks the nurse why the patient has bruising and petechiae across her abdomen. What is the RN's best response?
2. "Patients with Cushing disease have very fragile capillaries."
While the RN is performing an admission assessment on a patient with type 2 diabetes, the patient states that he routinely drinks 3 beers a day. What is the nurse's priority follow up question at this time?
2. "when during the day do you drink your beers?"
which client should the charge nurse assign to a new graduate RN who is orientating to the neurological unit?
2. A 67 year old client who had a stroke 3 days ago and has left-sided weakness.
Which client Should the charge nurse assign to the traveling nurse, new to neurologic nursing care, who has been on the neurological unit for 1 week?
2. A 68 year old client with chronic amyotrophic lateral sclerosis (ALS).
Which Patient should the charge nurse assign to the care of an LPN, under the supervision of the RN team leader?
2. An 83 year old patient with type 2 diabetes and chronic obstructive pulmonary disease.
A client with a spinal cord injury reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first?
2. Check the foley tubing for kinks and obstruction.
The nurse is floated from the ED to the neurological floor. Which action should the nurse delegate to the UAP when providing nursing care for a client with a spinal cord injury?
2. Checking and recording the client's respiratory status every 4 hours
Two UAP are assisting a patient with Cushing disease to move up in bed. Which action by the UAPs require the nurse's immediate intervention?
2. Grasping under the patient's arms to pull him up in bed.
For a patient with hyperthyroidism, which task should the nurse delegate to an experienced UAP?
2. Monitoring the apical pulse, blood pressure, and temperature every 4 hours.
The RN notes that a client with myasthenia gravis has an elevated temperature (102.2), an increased heart rate (120 beats/min), and a rise in blood pressure (158/94 mm Hg) and is incontinent of urine and stool. What is the nurses best action at this time?
2. Notify health care provider immediately.
The LPN is assigned to provide care for a patient with phechromocytoma. Which physical assessment technique should the RN instruct the LPN to avoid?
2. Palpating the abdomen in all four quadrants.
The RN is the preceptor for a senior nursing student who will teach a patient with diabetes about self-care during sick days. For which statement by the student must the RN intervene?
2. Test your urine for ketones whenever your blood glucose level is less than 240 mg/dL
The critical care nurse is assessing a client whose baseline Glasgow Coma Scale score in the emergency department was 5. The current GCS score is 3. What is the nurse's best interpretation of this finding?
2. The clients condition is deteriorating.
A client who recently started taking phenytoin to control simple partial seizures is seen in the outpatient clinic. Which information obtained during the nurse's chart review and assessment will be of greatest concern?
2. The gums appear enlarged and inflamed.
For which client with severe migraine headaches would the nurse question an order for sumatriptan?
2. a 48 year old client with hypertension
The RN is serving as preceptor to a new graduate nurse who has recently passed the RN licensure (NCLEX) examination. The new nurse has only been on the unit for 2 days. Which patient should be assigned to the new graduate nurse?
2. a 58 year old patient with diabetes who has cellulitis of the left ankle.
Which actions can the school nurse delegate to a experienced UAP who is working with a 7 year old child with type 1 diabetes in an elementary school? Select all that apply.
2. administering oral glucose tablets when blood glucose level falls below 60mg/dL (3.3 mmol/L) 4. obtaining blood glucose readings using the child's blood glucose monitor. 5. reminding the child to have a snack after the physical education class.
the nurse is responsible for the care of a patient with diabetes who is unable to swallow, is unconscious and seizing, and has a blood glucose of less than 20 mg/dl (1.1 mmol/L). which actions are most appropriate responses for this patient at this time? Select all that apply.
2. give glucagon 1 mg subcutaneously or intramuscularly (IM) 3. repeat the dose of glucagon in 10 minutes if the patient remains unconscious. 4. apply aspiration precautions because glucagon can cause vomiting. 6. notify the health care provider (HCP) immediately.
The nurse is providing care for a male patient with hypogonadotrpoin who is receiving sex steroid replacement therapy with testosterone. Which changes indicate to the nurse that therapy is successful? select all that apply.
2. increase libido 4. increased muscle mass 5. increased axillary hair growth
The nurse is preparing a care plan for a patient with Cushing Disease. Which abnormal lab value would the nurse expect? Select all that apply.
2. increased salivary cortisol level 3. increased urinary cortisol level 6. Increased serum cortisol level.
The nurse has just admitted a client with bacterial meningitis who reports having severe headache with photophobia and has a temperature of 102.6F orally. Which prescribed intervention should be implemented first?
2. infuse ceftriaxone 2000mg IV to treat the infection
In the emergency department, during initial assessment of a newly admitted patient with diabetes, the nurse discovers all of these findings. Which finding should be reported to the healthcare provider immediately?
2. rapid respiratory rate with deep inspirations.
An older patient with type 2 diabetes has cardiovascular autonomic neuropathy (CAN). which instruction would the nurse provide for the UAP assisting the patient with morning care?
2. sit the patient up slowly on the side of the bed before standing.
A 70 year old client with alcoholism who has become lethargic, confused, and incontinent during the last week is admitted to the emergency department. His wife tells the nurse that he fell down the stairs about a month ago but that "he didn't have a scratch afterward." which collaborative interventions will then nurse implement first?
2. transport the client to the radiology department for a computed tomography (CT) scan
The nurse is providing care for a client with an acute hemorrhagic stroke. The client's spouse tells the nurse that he has been reading a lot about strokes and asks why his wife has not received alteplase. What is the nurse's best response?
3. "Alteplase dissolves clots and may cause more bleeding into your wife's brain."
The patient with hyperparathyroidism who is not a candidate for surgery asks the nurse why she is receiving IV normal same and IC furosemide. What is the nurse's best response?
3. "Diuretic and hydration therapies are used to reduce your serum calcium."
The patient with type 2 diabetes has a health care provider prescription for NPO status for a cardiac catheterization. An LPN who is assigned to administer medications to this patient asks the supervising RN whether the patient should receive his ordered repaglinide. What is the RN's best response?
3. "No, because this drug should be given 1 to 30 minutes before meals and the patient is NPO."
Which client in the neurologic intensive care unit should the charge nurse assign to an RN who has been floated from the medical unit?
3. A 46 year old client who was admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due.
As the shift begins, the nurse is assigned to care for the following patients. Which patient should the nurse assess first?
3. A 58 year old patient with hypothyroidism and a heart rate of 48 beats/min.
The nurse is caring for the following patients with endocrine disorders. Which patient must the nurse assess first?
3. A 65 year old patient with addison disease whose morning potassium leve lis 6.2 mEq/L
The Nurse is assessing a newly admitted older adult with diabetes. Assessment reveaks abnormal appearance of the feet (see figure). The nurse recognizes this as which deformity?
3. Charcot foot deformity.
After a client has a seizure, which action can the nurse delegate to the unlicensed assistive personnel?
3. Checking the clients vital signs
The nurse is preparing a nursing care plan for a client with spinal cord injury for whom problems of decreased mobility and inability to perform activities of daily living (ADL's) have been identified. The client tells the nurse, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing concern takes priority?
3. Difficulty with coping.
A patient is admitted to the medical unit with possible graves disease (hyperthyroidism). Which assessment finding by the nurse supports this diagnosis?
3. Exophthalmos
The nurse is preparing to review a teaching plan for a patient with type 2 diabetes mellitus. To determine the patient's level of compliance with his prescribed diabetic regimen, which value would the nurse be sure to review?
3. Glycosylated hemoglobin (HgbA1c) level
A client with parkinson diseases has a problem with decrease mobility related to neuromuscular impairment. The nurse observes the UAP performing all of these actions. For which action must the nurse intervene?
3. Performing the client's complete bathing and oral care
An LPN is assigned to perform assessments on two patients with diabetes. Assessments reveals all of these findings. Which finding would the RN instruct the LPN to report immediately?
3. Profuse perspiration.
The nurse is evaluating a patient with diabetes for foot risk category. The patient lacks protective sensation and shows evidence of peripheral vascular disease. According to the American Diabetes Association (ADA) which foot risk category best fits this patient?
3. Risk category 2.
A patient has newly diagnosed type 2 diabetes. Which action should the RN assign to an LPN rather than an experienced UAP?
3. administering subcutaneous insulin on a sliding scale as needed.
A client with Guillain-Barre syndrome (GBS) is to undergo plasmapheresis to remove circulation antibodies thought to be responsible for the disease. Which client care action should the nurse delegate to the experienced UAP?
3. weigh the client before and after the procedure.
The nurse is instructing a senior nursing student on the techniques for palpation of the thyroid gland. What precaution would the nurse be sure to include when instructing the student about thyroid palpation?
4. Always palpate the thyroid gland gently.
A 24 year old patient with diabetes insipidus makes all of these statements when the nurse is preparing the patient for discharge from the hospital. Which statement indicates to the nurse that the patient needs additional teaching?
4. "I will gradually wean myself off the vasopressin."
A nursing student is teaching a client and family about epilepsy before the client's discharge. For which statement should the nurse intervene?
4. "Its OK to take over-the-counter medications."
A patient has newly diagnosed type 2 diabetes. which task should the RN delegate to an experienced UAP?
4. Checking the patient's glucose level before each meal.
A UAP tells the nurse that while assisting with the morning care of a postoperative patient with type 2 diabetes who has been given insulin, the patient asked if she will always need to take insulin now. What is the RN's priority for teaching the patient?
4. Discuss the relationship between illness and increased glucose levels.
A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment?
4. Monitor respiratory effort and oxygen saturation level
After the nurse receives the change-of-shift report at 7:00 AM, which client must the nurse assess first?
4. a 63 year old client with multiple sclerosis (MS) who has an oral temperature of 101.8F and flank pain.
Assessment findings for a patient with Cushing disease include all of the following. For which finding would the nurse notify the health care provider (HCP) immediately?
4. crackles bilaterally in the lower lobes of the lungs.
The RN is supervising a senior nursing student who is caring for a fresh postoperative patient who had a hypophysectomy. The nurse observes the student nurse perform all of these actions. for which action must the RN intervene?
4. encourage the patient to cough vigorously.
The experienced UAP has been delegated to take vital signs and check fingerstil glucose on a post-op patient with diabetes. Which vital sign change would the RN instruct the UAP to report immediately?
4. glucose increase from 190 to 236 mg/dL (10.6 to 13.1 mmol/L)
A patient with a pheochromocytoma underwent surgery to remove his adrenal glands. Which nursing intervention should the nurse delegate to a UAP?
4. monitoring lying and standing blood pressure every 4 hours with a cuff placed on the same arm.
While working in the diabetes clinic, the RN obtains the following information about an 8 year-old patient with type 1 diabetes. Which finding is most important to address when planning child and parent education?
4. morning preprandial glucose range of 55 to 70 mg/dL (3.1 to 3.9 mmol/L)
An LPN, under the RN's supervision, is assigned to provide nursing care for a client with Guillain=Barre syndrome (GBS). What observation should the LPN be instructed to report immediately?
4. shallow respirations and decreased breath sounds
A patient with type 1 diabetes reports feeling dizzy. What should the nurse do first?
4. use a glucometer to check the patient's glucose level.
The nurse is assessing a client with a neurological health problem and discovers a change in level of consciousness from alert to lethargic. What is the nurse's best action?
Contact the rapid response team
A patient is hospitalized with adrenocortical insufficiency. Which nursing activity should the nurse delegate to the UAP?
reminding the patient to change positions slowly.
