Med Surg 1 Final

A nurse is caring for a female client who has recurrent kidney stones and is scheduled for an intravenous pyelogram. Which of the following statements by the client should the nurse report to the provider? A. "I drink at least 2 quarts of fluid every day." B. "The last time I voided it was painful and red-tinged." C. "My period ended 2 days ago." D. "I don't eat shellfish because it gives me hives."

"I don't eat shellfish because it gives me hives." Rationale: The client says she experiences hives after eating shellfish, which indicates a sensitivity. The contrast dye typically used for an IVP is an iodine derivative, and the client with a shellfish sensitivity may have cross-sensitivity to iodine and a serious iodine allergy. This nurse should report these finding to the client's provider.

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? Select all that apply: 1. The client will list foods that are high in calcium, which should be avoided. 2. The client will walk for 30 min 5 days a week. 3. The client will increase calorie intake by 200 cal per day. 4. The client will replace cigarettes with smokeless tobacco products. 5. The client should be instructed to increase calcium and Vitamin D 6. The client should be instructed to decrease caloric intake

2. The client will walk for 30 min 5 days a week. 5. The client should be instructed to increase calcium and Vitamin D 6. The client should be instructed to decrease caloric intake Rationale: CDC recommendations include engaging in a moderate exercise, such as walking, for a total of 150 min each week.

A nurse is teaching a client who has recurrent urinary tract infections (UTIs) about prevention measures. Which of the following client statements indicates the need for further teaching? A. "I will need to wipe my perineal area from back to front after urination." B. "I will need to empty my bladder regularly and completely." C. "I will need to evacuate my bowels regularly." D. "I need to drink an adequate amount of liquid each day."

A. "I will need to wipe my perineal area from back to front after urination." Rationale: Wiping the perineal area from back to front increases the risk for urethral contamination and a resulting UTI. All other options are appropriate UTI prevention measures.

An older adult client in a long-term care facility has a stroke 4 weeks ago and has been unable to move independently since that time. The nurse caring for her should observe for which of the following findings that indicates a complication of immobility? A. A reddened area over the sacrum B. Stiffness in the lower extremities C. Difficulty moving the upper extremities D. Difficulty hearing some types of sounds

A. A reddened area over the sacrum Rationale: A reddened area over a bony prominence is a stage 1 pressure ulcer, a complication of immobility. If the nurse recognizes it at this stage and implements measures to avoid additional pressure, it might not progress to the next stage.

A nurse in a provider's office is reviewing the laboratory results of a client who takes furosemide for hypertension. The nurse notes that the client's potassium level is 3.3 mEq/L. The nurse should monitor the client for which of the following complications? A. Cardiac dysrhythmias B. Hypoglycemia C. Seizures D. Neurogenic shock

A. Cardiac dysrhythmias Rationale: This client's potassium level is below the expected reference range. Hypokalemia can cause a number of cardiac effects including flattened T waves, prominent U waves, and S-T depression.

A nurse is caring for a client who has hypoglycemia. The nurse should monitor the client for which of the following adverse effects of hypoglycemia? A.Decreased BP B.Fever C.increased urination D.Metabolic acidosis

A. Decreased blood pressure Rationale: A client who has hypoglycemia is at risk for hypotension. The nurse should monitor the clientfor hypotension

A client is admitted to the hospital for elective knee surgery to be performed the following day. The client tells the nurse that he has benign prostatic hyperplasia (BPH). Which assessment findings support the diagnosis of BPH? (Select all that apply) A. Increased time to void B. Fever C. Elevated white blood cell (WBC) count D. Urinary frequency E. Nocturia

A. Increased time to void D. Urinary frequency E. Nocturia Rationale: Clinical manifestations of BPH include weak urinary stream, increased time to void, hesitancy, incomplete bladder emptying, postvoid dribbling, frequency, urgency, incontinence, nocturia, dysuria, and bladder pain.

A nurse is assessing a client who has asthma. Which of the following areas should the nurse evaluate as the most reliable indicator of central cyanosis? A. Oral mucosa B. Conjunctivae C. Ear lobes D. Soles of the feet

A. Oral mucosa Rationale: According to evidence-based practice, the nurse should first monitor the client's tongue and lips for manifestations of central cyanosis because cyanosis is most evident in areas with minimal pigmentation.

A nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an H2 receptor antagonist (H2RA). Which of the following outcomes indicates the H2RA is therapeutic? A. Relief of heartburn B. Cessation of diarrhea C. Passage of flatus D. Absence of constipation

A. Relief of heartburn Rationale: H2RAs are used to treat duodenal ulcers and prevent their return. In over-the-counter strengths, these medications, such as cimetidine and famotidine, are used to relieve or prevent heartburn, acid indigestion, and sour stomach.

A nurse is assessing a client who is taking chlorothiazide sodium. The nurse recognizes which of the following as a manifestation of hypokalemia? A. Shallow Breaths B. Hypertensive crisis C. Diarrhea D. Hyperreflexia

A. Shallow Breaths Rationale: A client's shallow respirations are a sign of weakness in the accessory muscles of breathing, due to hypokalemia

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manisfestations should indicate to the nurse that the child's appendix is perforated? A. Sudden decrease in abdominal pain B. Absent Rovsing's sign C. Flaccid abdomen D. Low-grade fever

A. Sudden decrease in abdominal pain Rationale: A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.

Which rationale would the nurse use when teaching a client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing? A. decrease air trapping B. prevent bronchial dilation C. strengthen intercostal muscles D. reduce diaphragmatic excursion

A. decrease air trapping Rationale: Pursed-lip breathing prolongs the expiratory phase and increases airway positive pressure, leading to more complete expiration and reduced air trapping.

A nurse is caring for a client who reports recurrent flank pain, nausea, and vomiting for 24hrs. Which of the following actions is the nurse's priority? A. monitor intake and output B. strain the urine C. administer pain meds D. administer an antiemetic

Administer pain medication. Rationale: Using Maslow's hierarchy of needs, the nurse's priority is to meet the client's physiological need for comfort. Therefore, the first action the nurse should take is to administer pain medication to relieve the client's flank pain.

A nurse is teaching a pt who is scheduled for a cystoscopy. Which of the following information should the nurse include in the teaching? A. You should limit fluids for 12 hr following the procedure B. You may have pink tinged urine after this procedure C. You can eat a full liquid meal up to one hour before the procedure D. You will be placed on your right side during this procedure

B. "You may have pink tinged urine after this procedure" Rationale: The client may have blood-tinged, or pink, urine after the procedure. The client should report dark red urine because it is an indication of bleeding.

While conducting an​ assessment, the nurse concludes that a client is at risk for developing a deep venous thrombosis. Which assessment finding led the nurse to this​ conclusion? (Select all that​ apply.) A. Taking over-the-corner medication for arthritis B. A myocardial infarction 2 years ago C. Controlling type 2 diabetes mellitus diet & exercises D. Treatment for bladder cancer E. A history of atrial fibrilation

B. A myocardial infarction 2 years ago D. Treatment for bladder cancer E. A history of atrial fibrillation​ Rationale: Risk factors for the development of a DVT include​ cancer, atrial​ fibrillation, and myocardial infarction. Use of​ over-the-counter medication for arthritis and having controlled type 2 diabetes mellitus are not risk factors for the development of this health problem.

A nurse is assessing a client who has diabetes mellitus and reports foot pain. The nurse should evaluate the clientfor which of the following alterations as indications that the client has an infection? (Select all that apply.) A. Bradycardia B. An increase in neutrophils C. An increase in RBCs D. An increase in platelets E. Localized edema

B. An increase in neutrophils E. Localized edema Rationale: Bradycardia is incorrect. Tachycardia, not bradycardia, is an indication of infection.An increasein neutrophils is correct. During the inflammatory stage of wound healing, neutrophils move intothe interstitial spaces. About 24 hr later, macrophages replace them and ingest and destroymicro-organisms.An increase in RBCs is incorrect. An increase in the RBC count reflectspolycythemia, not infection.An increase in platelets is incorrect. An increase in the platelet countcan reflect malignancies, not infection.Localized edema is correct. Edema develops in the firststage of inflammation, when vascular and cellular responses cause fluid, WBCs, and protein topour into the interstitial spaces at the site of the invasion of micro-organisms. The accumulatedfluid appears as localized swelling or edema.

A nurse is teaching a client at high risk for osteoporosis about dietary measures she can take to increase her calcium level. Which of the following foods should the nurse advise the client to increase in her diet? A. Carrots B. Broccoli C. Cabbage D. Potatoes

B. Broccoli Rationale: Broccoli is high in calcium. Most vegetables contain considerably less calcium, except for kale, collard greens with stems, and turnip greens, which are also good sources of calcium.

A nurse is caring for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take to prevent infection? A. Replace the catheter every 3 days. B. Check the catheter tubing for kinks or twisting. C. Irrigate the catheter once each shift. D. Clean the perineal area with an antiseptic solution daily.

B. Check the catheter tubing for kinks or twisting. Rationale: These obstructions can affect the flow of urine causing pooling in the tubing that could backflow into the bladder.

A nurse is teaching a client who has urolithiasis (renal calculi). The nurse should explain that which of the following conditions can increase the risk for renal calculi? A. Protein in the urine B. Dehydration C. Iron Deficiency D. Obesity

B. Dehydration Rationale: Dehydration can cause hypercalcemia which increases the risk for renal stone formation. Inadequate fluid intake can result in urinary stasis and promote the formation of calculi.

A nurse is discussing urinary tract infections (UTI) with a client. Which of the following should the nurse include as a risk factor? A. COPD B. Diabetes mellitus C. Anemia D. Osteoporosis.

B. Diabetes mellitus. Rationale: Diabetes mellitus is considered a risk for factor for a UTI due to the increased amount of glucose present in the urine.

A nurse is teaching a client following a cystoscopy about his new prescription for tamsulosin Which of the following adverse effects should the nurse include in the teaching? A. Temporary loss of libido B. Dizziness C. Bradycardia D. Burning with urination

B. Dizziness Rationale: Lightheadedness or dizziness is likely with the first several doses. Clients should be taught to rise slowly and carefully from lying or sitting positions until the sensation disappears.

A nurse is reviewing the medical record of a client who has a peptic ulcer. Which of the following findings should the nurse recognize as a risk factor for this condition? A. History of bulimia B. History of NSAID use C. Drinks green tea D. Has a glass of wine with dinner each day

B. History of NSAID use Rationale: The nurse should recognize that long-term use of NSAIDs is a risk factor for peptic ulcer disease. NSAIDs break down the mucosal barrier and cause production of prostaglandins to decrease, which results in local gastric mucosal injury.

A nurse on a medical-surgical unit is performing an admission assessment of a client who has COPD with emphysema. The client reports that he has a frequent productive cough and is short of breath. The nurse should anticipate which of the following assessment findings for this client? A. Respiratory alkalosis B. Increased anteroposterior diameter of the chest C. Oxygen saturation level 96% D. Petechiae on chest

B. Increased anteroposterior diameter of the chest Rationale: The nurse should anticipate an increased anteroposterior diameter of the chest (barrel chest) because of chronic hyperinflation of the lungs.

A nurse plans care for a client with acute pancreatitis. Which intervention should the nurse include in this clients plan of care to reduce discomfort? A. Administer morphine sulfate intravenously every 4 hours as needed. B. Maintain nothing by mouth (NPO) and administer intravenous fluids. C. Provide small, frequent feedings with no concentrated sweets. D. Place the client in semi-Fowlers position with the head of bed elevated

B. Maintain nothing by mouth (NPO) and administer intravenous fluids. Rationale: The client should be kept NPO to reduce GI activity and reduce pancreatic enzyme production. IV fluids should be used to prevent dehydration. The client may need a nasogastric tube. Pain medications should be given around the clock and more frequently than every 4 to 6 hours. A fetal position with legs drawn up to the chest will promote comfort.

A nurse is caring for a client who has had a hemorrhagic stroke following a ruptured cerebral aneurysm. Which of the following manifestations should the nurse expect? A. Gradual onset of several hours B. Manifestations preceded by a severe headache C. Maintains consciousness D. History of neurological deficits lasting less than 1 hr.

B. Manifestations preceded by a severe headache Rationale: A hemorrhagic stroke is caused by bleeding into the brain tissues, ventricles, or subarachnoid space. It can be caused by hypertension, an aneurysm, or an arteriovenous malformation. A sudden, severe headache is an expected initial manifestation of a hemorrhagic stroke

A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? A. Administer glucagon for hyperglycemia. B. Obtain an influenza vaccine annually. C. Inject insulin in the deltoid muscle. D. Take glyburide with breakfast.

B. Obtain an influenza vaccine annually. Rationale: The client should obtain an influenza vaccine annually.

A nurse is teaching a client who is at risk for osteoporosis. Which for the following instructions should the nurse include? A. Take 400 IU of vitamin D supplement each day. B. Perform moderate-intensity exercise for 150 min per week. C. Take 250 mg of a calcium supplement each day. D. Perform vigorous exercise at least 2 times per week.

B. Perform moderate-intensity exercise for 150 min per week. Rationale: The client should perform moderate-intensity exercise for 150 min per week to strengthen bones and muscles and decrease the risk of osteoporosis.

A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of actions is the nurse's priority? A. Place a pillow under the child's head. B. Position the child side-lying. C. Loosen restrictive clothing. D. Clear the area of hazards.

B. Position the child side-lying. Rationale: This is the priority nursing action. To prevent aspiration due to vomiting, the nurse should place the child in a side-lying position.

A nurse is teaching a client who has cholecystitis about required dietary modifications. The nurse should include which of the following foods as appropriate for the clients diet? A. Creamed chicken B. Roast turkey C. Ice cream D. Macaroni and cheese

B. Roast Turkey Rationale: Roast turkey is a low-fat protein that is an appropriate choice for inclusion in the clients diet. Low-fat food decreases stimulation of the gallbladder, thereby reducing associated symptoms.

A nurse is providing teaching for a client who has anemia and a new prescription for ferrous sulfate liquid. Which of the following instructions should the nurse provide? A. Take the medication on an empty stomach to decrease gastrointestinal irritation. B. Take the medication with orange juice to enhance absorption. C. Take the medication with milk. D. Rinse the mouth before taking the iron.

B. Take the medication with orange juice to enhance absorption. Rationale: Taking iron on an empty stomach may increase gastrointestinal side effects. Ascorbic acid (vitamin C), found in orange juice, will enhance the absorption of iron and increase its bioavailability. This will also help to decrease the gastrointestinal side effects of iron. Iron should not be taken with milk or antacids, because it decreases the absorption. The client should rinse the mouth after taking the ferrous sulfate liquid to prevent the medication from staining the teeth.

The nurse should teach patients taking isoniazid to avoid alcohol because of the increased risk of A. central nervous system depression B. liver damage C. drug-resistant tuberculous organisms D. rapid drug metabolism

B. Taking isoniazid and alcohol in combination increases the risk of liver damage Rationale: Hepatotoxicity is an adverse effect of isoniazid, rifampin, and pyrazinamide.

The nurse is assigned to provide nursing care for a patient receiving mechanical ventilation. Which action should the nurse delegate to an experienced assistive personnel (AP)? A. Assessing the patient's respiratory status every 4 hours B. Taking vital signs and pulse oximetry readings every 4 hours C. Checking the ventilator settings to make sure they are as prescribed D. Observing whether the patient's tube needs suctioning every 2 hours

B. Taking vital signs and pulse oximetry readings every 4 hours Rationale: The AP's educational preparation includes measuring vital signs, and an experienced AP would have been taught and know how to check oxygen saturation by pulse oximetry. Assessing and observing the patient, as well as checking ventilator settings, require the additional education and skills of the RN

A nurse is planning care for a client who is scheduled for extracorporeal shock-wave lithotripsy (ESWL). The nurse should plan to monitor the client for which of the following adverse effects of ESWL?

Bruising Rationale: The nurse should monitor the client for bruising, swelling, pain, or numbness.

When preparing a clinic patient who has chronic obstructive pulmonary disease (COPD) for pulmonary spirometry, which question would the nurse ask? A. "Are you claustrophobic?" B. "Are you allergic to shellfish?" C. "Have you taken any bronchodilators today?" D. "Do you have any metal implants or prostheses?"

C. "Have you taken any bronchodilators today?" Rationale: Spirometry will help establish the COPD diagnosis. Bronchodilators should be avoided at least 6 hours before the test. Spirometry does not involve being placed in an enclosed area such as for magnetic resonance imaging (MRI). Contrast dye is not used for spirometry. The patient may still have spirometry done if metal implants or prostheses are present because they are contraindications for an MRI.

A nurse is reviewing discharge instructions with a client who has rheumatoid arthritis and a new prescription for prednisone. Which of the following statements by the client indicates an understanding of the teaching? A. "I should take my flu vaccine within one week of starting this medication." B. "I can expect a sore throat for the first week after starting this medication." C. "I should eat more bananas while taking this medication." D. "I should take aspirin for minor aches and pains while taking this medication."

C. "I should eat more bananas while taking this medication." Rationale: The nurse should instruct the client to eat more potassium-rich foods such as bananas and citrus fruits while taking this medication. Prednisone can cause a loss of potassium, and the nurse should instruct the about the manifestations of hypokalemia such as muscle weakness and cramping and to notify the provider should these occur.

A nurse is teaching about self-monitoring to a client who has type 1 diabetes mellitus. Which of the following statements by the client indicates an understanding of the teaching? A. "I will check my urine once a day for ketones." B. "I will notify my provider if pre-meal glucose is 120 mg/dL." C. "I will check my blood glucose every 4 hours when I am sick." D. "I will check blood glucose every 5 minutes when lightheaded."

C. "I will check my blood glucose every 4 hours when I am sick." Rationale: The client should follow specific guidelines when sick. The nurse should instruct the client to monitor blood glucose every 3 to 4 hr and continue to take insulin or oral antidiabetic agents. The client should consume 4 oz of sugar-free, noncaffeinated liquid every 30 min to prevent dehydration and eet carbohydrate needs through soft food if possible. If not, the client should consume liquids equal to usual carbohydrate content. The nurse should also instruct the client to test urine for ketones and report to provider if they are abnormal (the level should be negative to small).

19. Which of these laboratory test results will be most important for the nurse to monitor when evaluating the effects of therapy for a patient who has acute pancreatitis? A. Calcium B. Bilirubin C. Amylase and lipase D. Potassium

C. Amylase and lipase Rationale: Amylase and lipase is elevated in acute pancreatitis. Although changes in the other values may occur, they would not be as useful in evaluating whether the prescribed therapies have been effective.

A nurse is caring for a client who has right-sided paralysis from a stroke. Which of the following interventions should the nurse implement to prevent footdrop? A. Place sandbags to maintain right plantar flexion. B. Position soft pillows against the bottom of the feet. C. Apply a protective boot to the right ankle. D. Splint the right lower extremity to maintain proper alignment.

C. Apply a protective boot to the right ankle. Rationale: The nurse should apply padded splints or protective boots to the foot at a right angle to the leg to prevent footdrop.

A nurse is teaching a newly licensed nurse about informed consent. Which of the following should be included as a responsibility of the nurse in this process? A. Discuss the risks of the procedure with the client. B. Explain alternatives to the procedure to the client. C. Confirm that the client is competent to sign for the procedure. D. Inform the client about what will occur during the procedure

C. Confirm that the client is competent to sign for the procedure. Rationale: The nurse should confirm the client is competent, of legal age, voluntarily giving consent, and has been given adequate information about the procedure.

Which teaching is a priority for the client with gastroesophageal reflux?The nurse is planning the care of a client diagnosed with lower esophageal sphincterdysfunction. Which dietary modifications should be included in the plan of care? A. Allow any of the client's favorite foods as long as the amount of the food is limited. B. Have the client perform eructation exercises several times a day. C. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. D. Encourage the client to consume a glass of red wine with one (1) meal a day.

C. Eat four (4) to six (6) small meals a day and limit fluids during mealtimes. Rationale: The client is instructed to eat four to six small meals daily rather than three larger meals to avoid pressure in the stomach and delayed gastric emptying, which can increase reflux. Evening snacks, carbonated beverages, and acidic foods also should be avoided.

A nurse is providing discharge instructions to a client who developed deep-vein thrombosis (DVT) postoperatively and is prescribed anticoagulant therapy. Which of the following instructions should the nurse include? A. Applying cool compresses to her legs B. Wearing loose, non-constricting stockings C. Flexing her knees and feet frequently D. Taking an NSAID tablet daily

C. Flexing her knees and feet frequently Rationale: Leg, ankle, and foot exercises can help improve circulation and prevent venous stasis while the client is resting.

A nurse is reviewing the laboratory results of a male adult client who is at risk for peripheral arterial disease from atherosclerosis. The nurse should identify that which of the following results places the client at risk? A. Triglycerides 130 mg/dl B. Blood glucose 92 mg/dl C. LDL 172 mg/dl D. HDL 84 mg/dl

C. LDL 172 mg/dL Rationale: The nurse should identify that an LDL of 172 mg/dL places the client at risk for peripheral arterial disease from atherosclerosis. The expected reference range for an adult is less than 130 mg/dL.

Which information will the nurse include when teaching the patient with a urinary tract infection (UTI) about the use of phenazopyridine? A. Take phenazopyridine for at least 7 days. B. Phenazopyridine may cause photosensitivity C. Phenazopyridine may change the urine color D. Take phenazopyridine before sexual intercourse.

C. Phenazopyridine may change the urine color Rationale: Patients should be taught that phenazopyridine will color the urine deep orange. Urinary analgesics should only be needed for a few days until the prescribed antibiotics decrease the bacterial count. Phenazopyridine does not cause photosensitivity. Taking phenazopyridine before intercourse will not be helpful in reducing the risk for UTI.

Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? A. Even, unlabored respirations B. Absence of wheezes or crackles C. Pulse oximetry reading of 92% D. Respiratory rate of 18 breaths/min

C. Pulse oximetry reading of 92% Rationale: For the nursing diagnosis of impaired gas exchange, the best data for evaluation are arterial blood gases (ABGs) or pulse oximetry. The other data may indicate either improvement or impending respiratory failure caused by fatigue.

A nurse is reviewing the health history for a client who has angina pectoris and a prescription for propranolol hydrochloride PO 40 mg twice daily. Which of the following findings in the history should the nurse report to the provider? A. The client with a history of migraine headaches B. The client with a history of hypothyroidism C. The client with a history of bronchial asthma D. The client with a history of hypertension

C. The client with a history of bronchial asthma. Rationale: Beta-adrenergic blockers can cause bronchospasm in clients who have bronchial asthma; therefore, this is a contraindication to its use and should be reported to the provider.

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) A. at bedtime B. in the morning. C. with each meal. D. for abdominal pain

C. with each meal. Rationale: Pancreatic enzymes are used to help with digestion of nutrients and should be taken with every meal.

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. Which statement made by the client indicates an understanding of the teaching? A. "I am to take my blood sugar reading after meals." B. "Insulin allows me to eat ice cream at bedtime." C. "A weight reduction program will make me hypoglycemic." D. "I give the insulin injections in my abdominal area."

D. "I give the insulin injections in my abdominal area." Rationale: Pt should give insulin injections in one anatomic area for consistent day-to-day absorption. The abdomen is the area for fastest absorption.

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse question? A. Maintain NPO status. B. Monitor oral temperature every 4 hr. C. Medicate the client for pain every 4 hr as needed. D. Administer sodium biphosphate/sodium phosphate (Fleet Enema) today

D. Administer sodium biphosphate/sodium phosphate (Fleet Enema) today Rationale: Enemas and laxatives are contraindicated because they increase the volume in the bowel and can cause the inflamed appendix to rupture, increasing the risk for peritonitis

A nurse is caring for a client who has type 1 diabetes mellitus the nurse misread the client's morning blood glucose level of 210 mg per dL, instead of 120 mg per dL, and administered the wrong dose of insulin and which of the following actions should the nurse identify as a priority. A. Notify the nurse manager. B. Give the client 15 to 20 g of carbohydrate. C. Complete an incident report. D. Check the client's blood glucose level.

D. Check the client's blood glucose level. Rationale: The first action the nurse should take using the nursing process is to assess or collect data from the client. The nurse should immediately check the client's blood glucose level, expecting it to be low because of the unnecessary dose of insulin. If it is within the expected reference range, the nurse should continue to monitor the client for hypoglycemia.

A nurse is caring for an older adult client who has a urinary tract infection (UTI). Which of the following manifestations should the nurse identify as a finding specifically associated with this client? A. Urinary retention B. Low back pain C. Incontinence D. Confusion

D. Confusion Rationale: Confusion is a clinical finding of UTIs specifically associated with older adult clients.

A nurse is preparing to administer digoxin (Lanoxin) to a client who has heart failure. Which of the following actions is appropriate? A. Withholding the medication if the heart rate is above 100/min B. Instructing the client to eat foods that are low in potassium C. Measuring apical pulse rate for 30 seconds before administration D. Evaluating the client for nausea, vomiting, and anorexia

D. Evaluating the client for nausea, vomiting, and anorexia Rationale: Loss of appetite, nausea, vomiting, and blurred or yellow vision may be signs of digoxin toxicity.

A nurse is providing teaching to a pt who has hypertension and a new prescription for verapamil. Which of the following beverages should the nurse tell the pt to avoid while taking this medication? A. Milk B. Orange juice C. Coffee D. Grapefruit juice

D. Grapefruit juice Rationale: Grapefruit juice increases blood levels of verapamil, a calcium channel blocker, by inhibiting its metabolism. The excess amount of medication can intensify the medication's hypotensive effects, putting the client at risk for syncope and dizziness.

Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? A. Nausea and vomiting B. Hypotonic bowel sounds C. Abdominal tenderness and guarding D. Muscle twitching and finger numbness

D. Muscle twitching and finger numbness Rationale: Muscle twitching and finger numbness indicate hypocalcemia, which may lead to tetany unless calcium gluconate is administered. Although the other findings should also be reported to the health care provider, they do not indicate complications that require rapid action.

A nurse is assessing a toddler who has heart failure. Which of the following findings should the nurse expect? A. Weight loss B. Increased urine output C. Bradycardia D. Orthopnea

D. Orthopnea Rationale: A toddler who has heart failure has increased venous return to the heart and lungs, which leads to pulmonary congestion. The congestion causes orthopnea, or difficulty breathing, while lying down. Having the toddler sit up decreases venous return, as well as pressure the abdominal organs have on the diaphragm. This decrease in pressure improves breathing and oxygenation.

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy. B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. C. The client who has end-stage renal failure and is scheduled for dialysis today. D. The client who has gastroenteritis and is febrile.

D. The client who has gastroenteritis and is febrile. Rationale: This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.

Which information given by a patient when the nurse is taking a health history indicates that screening for hepatitis C should be done? A. The patient eats frequent meals in fast-food restaurants. B. The patient recently traveled to an undeveloped country. C. The patient had a blood transfusion after surgery in 1998. D. The patient reports a one-time use of IV drugs 20 years ago.

D. The patient reports a one-time use of IV drugs 20 years ago. Rationale: Any patient with a history of IV drug use should be tested for hepatitis C. Blood transfusions given after 1992, when an antibody test for hepatitis C became available, do not pose a risk for hepatitis C. Hepatitis C is not spread by the oral-fecal route and therefore is not caused by contaminated food or by traveling in underdeveloped countries.

A nurse is preparing to administer dabigatran to a client who has atrial fibrillation. The nurse should explain that the purpose of this medication is which of the following? A. to convert atrial fibrillation to sinus rhythm B. to dissolve clots in the bloodstream C. to slow the response of the ventricles to the fast atrial impulses D. to reduce the risk of stroke in clients who have atrial fibrillation.

D. to reduce the risk of stroke in clients who have atrial fibrillation. Rationale: Clients who have atrial fibrillation are at an increased risk for thrombus formation and subsequent embolization to the brain. Anticoagulants, such as dabigatran, help prevent thrombus formation.

When caring for a patient following an incisional cholecystectomy for cholelithiasis, the nurse places the highest priority on assisting the patient to A. choose low-fat foods from the menu. B. perform leg exercises hourly while awake. C. ambulate the evening of the operative day. D. turn, cough, and deep breathe every 2 hours

D. turn, cough, and deep breathe every 2 hours Rationale: Postoperative nursing care after a cholecystectomy focuses on prevention of respiratory complications because the surgical incision is high in the abdomen and impairs coughing and deep breathing.

Which information will the nurse include in the asthma teaching plan for a patient being discharged? A. Use the inhaled corticosteroid when shortness of breath occurs. B.Inhale slowly and deeply when using the dry powder inhaler (DPI). C.Hold your breath for 5 seconds after using the bronchodilator inhaler. D.Tremors are an expected side effect of rapidly acting bronchodilators.

D.Tremors are an expected side effect of rapidly acting bronchodilators. Rationale: Tremors are a common side effect of short-acting β2-adrenergic (SABA) medications and not a reason to avoid using the SABA inhaler. Inhaled corticosteroids do not act rapidly to reduce dyspnea. Rapid inhalation is needed when using a DPI. The patient should hold the breath for 10 seconds after using inhalers.

A nurse is receiving a client who is immediately postoperative following hip arthroplasty. Which of the following medications should the nurse plan to administer for DVT prophylaxis?

Enoxaparin subcutaneous Rationale: Enoxaparin is a low molecular heparin that inhibits thrombus and clot formation. Preventive doses of enoxaparin are low and the client does not require monitoring of prothrombin time or activated partial thromboplastin time, making it the preferred treatment for DVT prophylaxis following orthopedic surgery.

A nurse is preparing a client who is scheduled for an echocardiogram the following day. Which of the following instruction should the nurse include about the test? It might cause slight discomfort in the chest area It takes about five or 10 minutes It requires lying quietly on one side It is best to have no food or beverages the day of the test

It requires the patient to lie quietly on the left side with slight head elevation Rationale: For an echocardiogram, the client lies quietly on the left side with slight head elevation.