med surg 2 - test 1

What effect on circulating levels of sodium and glucose does the nurse expect in a client who has been taking an oral cortisol preparation for 2 years because of a respiratory problem?

A. Decreased sodium; decreased glucose B. Decreased sodium; increased glucose C. Increased sodium; decreased glucose D. Increased sodium; increased glucose ANSWER D

Which precaution or action is most important for the nurse to teach the client who is to collect a 24-hour urine specimen for endocrine testing?

A. Eat a normal diet during the collection period. B. Wear gloves when you urinate to prevent contamination of the specimen. C. Urinate at the end of 24 hours and add that sample to the collection container. D. Avoid walking, running, dancing, or any vigorous exercise during the collection period. ANSWER C

When taking the blood pressure of a client receiving treatment for hyperparathyroidism, the nurse observes the client's hand to undergo flexion contractions. What is the nurse's interpretation of this observation?

A. Hyperphosphatemia B. Hypophosphatemia C. Hypercalcemia D. Hypocalcemia ANSWER D

Which manifestations are most often seen in general hyperthyroidism? Select all that apply.

A. Increased appetite B. Cold intolerance C. Constipation D. Increased sweating E. Insomnia F. Palpitations G. Tremors H. Weight gain ANSWER A,D,E,F,G

Which blood test result for a client being assessed for a hematologic problem indicates to the nurse that chronic anemia is likely?

A. International normalized ratio (INR) is 0.9 B. Platelet count of 180,000/mm3 C. Reticulocyte value of 14% D. Hematocrit of 27% ANSWER C

What type of acid-base problem does the nurse expect in a client who is being insufficiently mechanically ventilated and whose most recent arterial blood gas results include a pH of 7.29?

A. Metabolic acidosis with an acid excess B. Metabolic acidosis with a base deficit C. Respiratory acidosis with an acid excess D. Respiratory acidosis with a base deficit ANSWER C

Which new assessment finding in a client with sickle cell disease who currently is in crises does the nurse report immediately to the health care provider?

A. Pain in the right hip with limited range of motion B. Slow capillary refill in the toes of the right foot C. Yellow appearance of the roof of the mouth D. Facial drooping on the right side ANSWER D

Which assessment finding indicates to the nurse that fluid resuscitation therapy for the client with isotonic dehydration is effective?

A. Respiratory rate has changed from 16 to 18 breaths/min. B. Urine specific gravity has increased from 1.040 to 1.050. C. Neck veins are flat when the client moves to a sitting position. D. Pulse pressure has changed from 22 mm Hg to 32 mm Hg ANSWER D

Which condition or manifestation in the client with a serum sodium level of 149 mEq/L indicates to the nurse that this electrolyte imbalance may be caused by excessive fluid loss?

A. The client has twitching muscle contractions in the lower extremities. B. The client's skin is cool and clammy. C. The urine specific gravity is increased. D. The hematocrit is 52%. ANSWER D

The blood of a client who has chronic myelogenous leukemia shows a high percentage of blast cells and promyelocytes. What is the nurse's correct interpretation of this test result?

A. The client's risk for infection is decreasing. B. The disease has become more aggressive. C. The drug therapy for the disease is effective. D. The type of leukemia is now lymphocytic rather than myelogenous. ANSWER B

The client is 3 weeks post-transplant from an allogeneic stem cell transplantation for acute lymphocytic leukemia. There is now some peeling of the client's skin on the palms of the hands and the soles of the feet. Which additional assessment data supports the nurse's suspicion of possible graft-versus-host disease (GVHD)?

A. The client's temperature is slightly below normal. B. Today's platelet count is 5,000/mm3 and the WBCs are low. C. The client has had 6 to 10 watery stools daily for 3 days. D. The client's urine output is less than 800 mL in 24 hours. ANSWER C

Why is it important for the nurse to teach the client starting on the anticoagulant warfarin (Coumadin) to limit his or her intake of leafy green vegetables?

A. These foods contain vitamin K, which can increase the effects of warfarin. B. These foods contain vitamin K, which can reduce the effects of warfarin. C. These foods enhance aspirin activity and increase the risk for bleeding in the person who also takes warfarin. D. These foods reduce aspirin activity and increase the risk for pulmonary embolism in the person who also takes warfarin. ANSWER B

Which urine properties indicate to the nurse that the client with syndrome of inappropriate (SIADH) antidiuretic hormone is responding to interventions?

A. Urine output volume increased; urine specific gravity increased B. Urine output volume increased; urine specific gravity decreased C. Urine output volume decreased; urine specific gravity increased D. Urine output volume decreased; urine specific gravity decreased ANSWER B

Which intervention is most important for the nurse to teach the client with polycythemia vera to prevent injury as a result of the increased bleeding tendency?

A. Use a soft-bristled toothbrush. B. Drink at least 3 liters of liquids per day. C. Wear gloves and socks outdoors in cool weather. D. Exercise slowly and only on the advice of your physician. ANSWER A

Which question is most important for the nurse to ask the client who has a serum potassium level of 2.9 mEq/L?

A. "Do you use sugar substitutes?" B. "Do you use diuretics or laxatives?" C. "Have you had any muscle twitches or cramps, especially at night? D. "Have you or any member of your family ever been diagnosed with lung disease?" ANSWER B

The client who is about to have a unilateral adrenalectomy for an adenoma that is causing hypercortisolism asks the nurse if she will have to continue the severe sodium restriction after surgery. What is the nurse's best response?

A. "No, once the tumor has been removed and your cortisol levels have normalized, you will not retain excess sodium anymore." B. "No, after surgery you will have to take oral cortisol, which can easily be controlled so that your sodium levels do not rise." C. Yes, the fact that you are retaining sodium and have high blood pressure is related to your age and lifestyle, not the tumor." D. "Yes, sodium is very bad for people and everyone needs to eliminate sodium completely from their diets for the rest of their lives." ANSWER A

Which intervention is most important for the nurse to teach the client who is at continuing risk for hypercalcemia and has normal kidney function?

A. "Report a weight gain of 1 lb or more a day to your health care provider immediately." B. "Keep track of the number of bowel movements you have each day." C. "Avoid taking aspirin or any aspirin-containing products." D. "Be sure to drink at least 2 liters of fluids each day." ANSWER D

For which client does the nurse question the prescription of androgen replacement therapy?

A. 35-year-old man who has had a vasectomy B. 48-year old man who takes prednisone for severe asthma C. 62-year-old man who has a history of prostate cancer D. 70-year-old man who has hypertension and type 2 diabetes ANSWER C

For which assessment finding in a client who has severe hyperthyroidism does the nurse notify the Rapid Response Team?

A. An increase in premature ventricular heart contractions from 4 per minute to 5 per minute B. An increase in or widening of pulse pressure from 40 mm Hg to 46 mm Hg C. An increase in temperature from 99.5° F (37.5° C) to 101.3° F (38.5° C) D. An increase of 20 mL of urine output per hour ANSWER C

The nurse who just came on duty observes that the client, whose blood type is AB negative, is receiving a transfusion with type O negative packed red blood cells. What is the nurse's best first action?

A. Call the blood bank. B. Take and record the client's vital signs. C. Stop the transfusion and keep the IV open. D. Document the observation as the only action. ANSWER B