Med surg exam 1 study guide

A nurse in an emergency department is caring for a client who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. The nurse should anticipate which of the following prescriptions from the provider?

0.9% sodium chloride IV bolus Answer Rationale: The nurse should expect a prescription for an IV bolus of 0.9% sodium chloride to be administered at 15 to 20 mL/kg/hr for the first hour to restore volume and maintain perfusion to the vital organs.

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH) and a sodium level of 123 mEq/L. Which of the following prescriptions should the nurse anticipate?

Restrict fluid intake to 1,000 mL per day

A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury. Which of the following findings should the nurse identify as indicating an increased risk of acute kidney injury (AKI)?

Serum creatinine 1.8 mg/dL (0.6 to 1.2 is the norm)

A nurse is teaching the family of a client who has a new diagnosis of epilepsy about actions to take if the client experiences a seizure. Which of the following instructions should the nurse include in the teaching?

"Move objects away from the client."

A nurse is assessing a client who has type 1 diabetes mellitus and finds the client lying in bed, sweating, and reporting feeling anxious. Which of the following complications should the nurse suspect

Hypoglycemia Answer Rationale: Manifestations of hypoglycemia include sweating, tachycardia, tremors, palpitations, hunger, and anxiety

A nurse is reviewing the arterial blood gas values of a client who has chronic kidney disease. Which of the following sets of values should the nurse expect? pH 7.25, HCO3- 19 mEq/L, PaCO2 30 mm Hg

metabolic acidosis is characterized by a low HCO3-, a low pH, and a low or normal PaCO2.

)A client is admitted to the emergency room with a respiratory rate of 7/ min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L

respiratory acidosis

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect?

widened qrs complexes

A nurse is caring for a client immediately following a hemodialysis treatment. For which of the following manifestations will the nurse administer a PRN dose of phenytoin?

Headache, restlessness

)A nurse is reviewing the laboratory results of a client who is at risk for developing diabetes mellitus. The nurse should recognize that which of the following results indicates the client meets the criteria for diagnosis of diabetes mellitus?

Fasting blood glucose 155 mg/dL Answer Rationale: A fasting blood glucose above 126 mg/dL meets the criteria for a diagnosis of diabetes mellitus.

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially?

Respiratory acidosis Answer Rationale: Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion of it, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation from anesthetics or opioids.

A nurse is assessing a client who has hypokalemia as a result of nausea, vomiting, and diarrhea. Which of the following findings should the nurse expect?

Weak, irregular pulse Answer Rationale: Common manifestations of potassium depletion include a weak and irregular pulse, muscle weakness, fatigue, and ventricular dysrhythmias.

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next?

assess cranial nerves

A nurse is caring for a client who has nephrotic syndrome and is receiving high-dose corticosteroid therapy. For which of the following electrolyte imbalances should the nurse monitor?

hypokalemia

A nurse enters a client's room and finds the client on the floor having a seizure. Which of the following actions should the nurse take?

place the client on his side

)A nurse is reviewing guidelines to prevent DKA during periods of illness with a client who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

"Check your urine for ketones when blood glucose levels are greater than 240 mg/dL."

A nurse is providing teaching to a client who has nephrotic syndrome. The nurse should recognize that which of the following client statements indicates a need for further teaching?

"I should increase my sodium intake." A client who has nephrotic syndrome should consume a low-sodium diet to reduce edema and control hypertension.

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

"Maintain stable blood glucose levels."

A nurse is caring for a client who has diabetic ketoacidosis. Which of the following manifestations should the nurse expect?

Acetone odor to breath Answer Rationale: Because of the lack of insulin, the body is unable to use glucose and instead breaks down fats resulting in excessive ketones. The large amount of ketones causes the body to become acidotic and causes a fruity, or acetone odor to the breath

)A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention?

Administer oxygen via face mask. Answer Rationale: The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.

A nurse is reviewing the BUN and creatinine levels of an older adult client who has chronic kidney disease. The nurse should expect which of the following findings?

BUN 45 mg/dL and creatinine 8 mg/dL Answer Rationale: An elevation of both BUN and creatinine is an expected finding of chronic kidney disease.

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?

Cardiac dysrhythmias Answer 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 assessing a client determines that he is in the compensatory stage of shock. Which of the following findings support this conclusion?

Confusion Answer Rationale: Confusion is a manifestation of the compensatory stage of shock. Other manifestations include decreased urinary output, cold and clammy skin, and respiratory alkalosis.

A nurse is assessing a client who has Graves' disease. The nurse should expect which of the following laboratory results?

Decreased thyroid-stimulating hormone (TSH) level Answer Rationale: The nurse should expect a TSH level below the expected reference range in a client who has Graves' disease

A nurse is teaching a client who has type 1 diabetes mellitus about exercise. Which of the following instructions should the nurse include?

Do not exercise if ketones are present in your urine.

A nurse is planning care for a client who is being treated with chemotherapy and radiation for metastatic breast cancer, and who has neutropenia. The nurse should include which of the following restrictions in the client's plan of care?

Fresh flowers and potted plants in the room

A nurse in a community clinic is assessing an older adult client for manifestations of dehydration. Which of the following findings should the nurse expect?

Furrows in the tongue Answer Rationale: In older adult clients who have dehydration, the surface of the tongue will be dry with deep furrows.

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect?

Hemorrhagic stroke Answer Rationale: A client who has a hemorrhagic stroke often experiences a sudden onset of symptoms including sudden onset of a severe headache, a decrease in the level of consciousness, and seizures. Hemorrhagic strokes occur when bleeding occurs in the brain caused by the rupture of an aneurysm or arteriovenous malformation, hypertension and atherosclerosis, or trauma.

A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take? (Select all that apply.)

Loosen restrictive clothing. Place a pillow under the client's head.

A nurse is caring for a client who has type 1 diabetes mellitus. The nurse misread the client's morning blood glucose level as 210 mg/dL instead of 120 mg/dL and administered the insulin dose appropriate for a reading over 200 mg/dL before the client's breakfast. Which of the following actions is the nurse's priority?

Monitor the client for hypoglycemia. Answer 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 excessive dose of insulin. If it is within the expected reference range, the nurse should continue to monitor the client for signs of hypoglycemia

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect?

PaCO2 50 mm Hg

A nurse enters a client's room and finds him on the floor in the clonic phase of a tonic-clonic seizure. Which of the following actions should the nurse take?

Place a pillow under the client's head.

)A nurse is creating a plan of care for a client who has a history of tonicclonic seizure disorder. Which of the following interventions should the nurse include? (Select all that apply.)

Provide a suction setup at the bedside. Elevate the side rails near the head when the client is in bed. Place the bed in the lowest position. Keep an oxygen setup at the bedside.

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances?

Respiratory acidosis Answer Rationale: With uncompensated respiratory acidosis, the pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg

A nursing is providing dietary teaching for a client who has Cushing's disease. Which of the following recommendations should nurse include in the teaching?

Restrict sodium intake. Answer Rationale: The nurse should recommend the client to restrict sodium intake to control fluid volume. This restriction can range from "no-added-salt" to table foods to a restriction of 2 g/day

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

This test determines whether your thyroid gland is overactive, appropriately active, or underactive."

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

Thyroid stimulating hormone (TSH)

A nurse is assessing a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Urine specific gravity 1.002 Answer Rationale: The nurse should expect a client who has diabetes insipidus to have diluted urine with a specific gravity less than 1.005.

A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. The nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the medication?

Urine specific gravity 1.015 Answer Rationale: A therapeutic effect of the medication would be urine specific gravity within the expected reference range, which is 1.010-1.025

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

Verify the most recent calcium level.

A nurse is assessing a client who has hypothyroidism. The nurse should expect which of the following findings?

Weight gain Answer Rationale: The nurse should expect to find weight gain in clients who have hypothyroidism, even with no change in dietary intake.

A nurse is reviewing the medical records of four clients who have an acid-base imbalance. The nurse should recognize that which of the following clients is at risk for metabolic acidosis?

client with diarrhea

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?

confusion

A nurse is collecting the medical history from a client who has manifestations of syndrome of inappropriate antidiuretic hormone (SIADH). The nurse should ask the client if he has a history of which of the following conditions that can cause SIADH?

lung cancer

)A nurse is caring for a client who has acute kidney injury (AKI). Which of the following arterial blood gas values would the nurse expect this client to have?

metabolic acidosis

)A nurse working on a medical unit is caring for a client who is prescribed seizure precautions. Which of the following interventions should the nurse include in the client's plan of care?

obtain iv access

A nurse is assessing a client who had a craniotomy and has developed syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following manifestations should the nurse anticipate?

oliguria (little urine)

)A nurse is reviewing the arterial blood gas (ABG) results of a client who the provider suspects has metabolic acidosis. Which of the following results should the nurse expect to see?

pH below 7.35 Answer Rationale: With acidosis, the pH is below 7.35. However, the pH alone does not indicate whether the problem is metabolic or respiratory. A pH above 7.45 indicates alkalosis.

A nurse is reviewing the laboratory data of a client following a hemodialysis treatment. The nurse should expect to find a decrease in which of the following laboratory values?

potassium

A nurse is reviewing the arterial blood gas values for a client. The pH is 7.32, PaCO2 48 mm Hg and the HCO3 is 23 mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances?

respiratory acidosis

)A nurse is in a client's room when the client begins having a tonic-clonic seizure. Which of the following actions should the nurse take first?

turn the clients head to the side