Med-Surg Final

The nurse is caring for a client with liver failure. Which nursing action is a high priority for this client? a. Assessing for signs of bleeding b. Monitoring blood pressure hourly c. Auscultation for bowel sounds d. Assessing for deep vein thrombosis

A. Assess for signs of bleeding?

A key component in the etiology of hepatic encephalopathy is: a. hyperglycemia. b. reduced blood flow to the brain. c. high ammonia levels in the systemic circulation. d. fatty infiltration of the liver.

c. high ammonia levels in the systemic circulation.

A nurse is caring for a patient who is receiving peripheral intravenous (IV) therapy. When the nurse is flushing the patient's peripheral IV, the patient reports pain. Upon assessment, the nurse notices a red streak that is warm to the touch. What is the nurse's initial action? Answers: a. Assign an infiltration grade. b. Record a phlebitis grade of 4. c. Apply moist compress. d. Discontinue the IV.

D. Discontinue the IV

A patient's peripheral parenteral nutrition (PN) bag is nearly empty and a new PN bag has not arrived yet from the pharmacy. Which intervention is the priority? a.Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy. b.Monitor the patient's capillary blood glucose until a new PN bag is hung. c.Decrease the rate of the current PN infusion to 10 mL/hr until the new bag arrives. d.Flush the peripheral line with saline and wait until the new PN bag is available

Infuse 5% dextrose in water until the new PN bag is delivered from the pharmacy.

Which instruction will the nurse give the client to prevent nighttime reflux? a. "Elevate the head of the bed 6 to 8 inches for sleep." b. "Sleep in the right lateral decubitus position." c. "Have a light evening snack before bedtime." d. "Have alcoholic beverages early in the evening."

a. "Elevate the head of the bed 6 to 8 inches for sleep."

A client who has had a colostomy placed in the ascending colon expresses concern that the effluent collected in the colostomy pouch has remained liquid for 2 weeks after surgery. Which is the nurse's best response? a. "This is normal for your type of colostomy." b. "You should add extra fiber to your diet to stop the diarrhea." c. "Your stool will gradually become firmer over the next few weeks." d. "I will let the doctor know so that he can look into it."

a. "This is normal for your type of colostomy."

After completing assessment rounds, which of the following should the nurse discuss with the physician first? a. A client with hepatitis whose pulse was 84 and regular and is now 118 and irregular. b. A client with stable vital signs recieving IV Cipro for 1 day and has developed a rash on the chest and arms. c. A client with pancreatitis whose family requests to speak with the physician regarding the treatment plan. d. A client with cirrhosis who is depressed and has refused to eat for the past few days.

a. A client with hepatitis whose pulse was 84 and regular and is now 118 and irregular.

The nurse correlates which rationale for a protein-restricted diet in the client with portal-systemic encephalopathy (PSE)? a. A low-protein diet will help reduce the amount of ammonia in the blood. b. The diet will give the liver a chance to rest and decrease hepatomegaly. c. A low-protein diet will help restore liver function and metabolism. d. Once albumin levels are normal, less protein is needed to prevent fluid from leaking into the abdomen.

a. A low-protein diet will help reduce the amount of ammonia in the blood.

A client with esophageal reflux who experiences regurgitation while lying flat is at risk for which complication? a. Aspiration b. Curling's Ulcer c. Xerostomia d. Hypokalemia

a. Aspiration

The nurse monitors for which clinical manifestation in the client with a decreased fecal urobilinogen concentration? a. Clay-colored stools b. Petechiae c. Melena d. Asterixis

a. Clay-colored stools

The nurse notes frank red blood in the drainage container from the nasogastric (NG) tube of a client who is 2 days post esophagogastrostomy. Which is the nurse's priority intervention? a. Notifying the physician that the suture line is bleeding b. Documenting the drainage c. Irrigating the NG tube d. Repositioning the tube in the opposite nostril

a. Notifying the physician that the suture line is bleeding

When caring for a 63-year-old woman with a nasogastric tube in place for enteral feedings, the nurse will a. flush the tubing before and after medication administration. b. replace the tube every 3 days to avoid mucosal damage. c. avoid giving medications through the feeding tube. d. assist the patient to a position of comfort using 1 pillow.

a. flush the tubing before and after medication administration.

A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? Answers: a. Apply oxygen by mask or nasal cannula. b. Measure intake and output every 4 hours. c. Place the client in a high-Fowler's position. d. Increase the IV flow rate to 250 mL/hr.

a. Apply oxygen by mask or nasal cannula.

The nurse is caring for a patient with hyperkalemia. Which body system assessment is the priority? Answers: a. Cardiac b. Respiratory c. Gastrointestinal d. Neurological

a. Cardiac

The nurse observes that the patient's calcium is elevated. When checking the phosphate level, what does the nurse expect to see? Answers: a. Decreased b. Increased c. No change in phosphate d. Equal to calcium

a. Decreased

The nurse is caring for a patient who has a calcium level of 12.1 mg/dL. Which nursing action should the nurse include on the care plan? Answers: a. Encourage fluid intake up to 4000 mL every day. b. Monitor for Trousseau's and Chvostek's signs. c. Maintain the patient on bed rest. d. Auscultate lung sounds every 4 hours.

a. Encourage fluid intake up to 4000 mL every day.

The nurse assesses a patient who has been hospitalized for 2 days. The patient has been receiving normal saline IV at 100 mL/hr, has a nasogastric tube to low suction, and is NPO. Which assessment finding would be a priority for the nurse to report to the health care provider? Answers: a. Gradually decreasing level of consciousness (LOC) b. Oral temperature of 100.1° F c. Serum sodium level of 138 mEq/L (138 mmol/L) d. Weight gain of 2 pounds (1 kg) above the admission weight

a. Gradually decreasing level of consciousness (LOC)

After teaching a client who is prescribed a restricted sodium diet, a nurse assesses the client's understanding. Which food choice for lunch indicates the client correctly understood the teaching? Answers: a. Grilled chicken breast with glazed carrots b. Salami and cheese on whole wheat crackers c. Slices of smoked ham with potato salad d. Bowl of tomato soup with a grilled cheese sandwich

a. Grilled chicken breast with glazed carrots

A 28-year-old male patient with type 1 Diabetes reports how he manages his exercise and glucose control. Which statement made by the patient is incorrect? a. I increase daily exercise when ketones are present in the urine b. I eat a peanut butter sandwich before going on a bicycle ride c. I always carry hard candies when engaging in exercise d. I go for a vigorous walk when my glucose is 200 mg/dL

a. I increase daily exercise when ketones are present in the urine

An older patient receiving continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result should the nurse report to the health care provider immediately? Answers: a. Na+ 154 mEq/L (154 mmol/L) b. K+ 3.4 mEq/L (3.4 mmol/L) c. Ca+2 7.8 mg/dL (1.95 mmol/L) d. PO4-3 4.8 mg/dL (1.55 mmol/L)

a. Na+ 154 mEq/L (154 mmol/L)

Following a thyroidectomy, a patient complains of "a tingling feeling around my mouth." Which assessment should the nurse complete immediately? Answers: a. Presence of the Chvostek's sign b. Abnormal serum potassium level c. Bleeding on the patient's dressing d. Decreased thyroid hormone level

a. Presence of the Chvostek's sign

A 63 year-old patient with primary hyperparathyroidism has a serum phosphorus level of 1.7 mg/dL (0.55 mmol/L) and calcium of 14 mg/dL (3.5 mmol/L). Which nursing action should be included in the plan of care? a. encourage 4000 mL of fluids daily b. restrict the patient to bed rest c. institue routine seizure precautions d. assess for a positive Chvostek's sign

a. encourage 4000 mL of fluids daily

A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this client's teaching (select all that apply). a. increase calorie intake b. increase carbohydrates c. decrease fats d. increase proteins e. supplemental vitamins

a. increase calorie intake b. increase carbohydrates d. increase proteins

A major focus of the dietary prescription for people who have type 2 diabetes is to: a. lose weight b. avoid snacks between meals c. avoid foods that contain sugar d. eat more fruits and vegetables

a. lose weight

Which lab value reported to the nurse by the unlicensed assistant personnel (UAP) indicates the most urgent need for the nurse's assessment of the patient? a. noon blood glucose of 40 mg/dL b. bedtime glucose of 140 mg/dL c. 2-hr postprandial glucose of 220 mg/dL d. fasting blood glucose of 130 mg/dL

a. noon blood glucose of 40 mg/dL

The nurse recognizes which client as being at greatest risk of developing hepatitis B? a. A businessman who travels frequently b. A college student who has had several sexual partners c. An older woman who has eaten raw shellfish d. A woman who takes acetaminophen daily for headaches

b. A college student who has had several sexual partners

The nurse is caring for a client who just had an esophagogastroduodenoscopy (EGD) completed. The client tells the nurse that her mouth is very dry after the procedure. Which is the nurse's best action? a. Provide the client with a few ice chips. b. Assess the client's gag reflex. c. Offer the client sips of clear liquids. d. Keep the client NPO.

b. Assess the client's gag reflex.

Which laboratory result will the nurse expect to find in a client with pancreatitis? a. Serum sodium 140 mEq/L b. Serum amylase, 950 IU/L c. Total bilirubin, 0.2 mg/dL d. Alkaline phosphatase, 47 U/L

b. Serum amylase, 950 IU/L

The nurse recognizes that palmer erythema is consistent with which assessment finding? a. Jaundice of the sclera b. Warm and bright red palms c. Purpuric lesions on the extremities d. A fruity or musty breath odor

b. Warm and bright red palms

A nurse teaches a client who is at risk for mild hypernatremia. Which statement should the nurse include in this client's teaching? Answers: a. "Weigh yourself every morning and every night." b. "Read food labels to determine sodium content." c. "Bake or grill the meat rather than frying it." d. "Check your radial pulse twice a day."

b. "Read food labels to determine sodium content."

A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? Answers: a. A 55-year-old receiving hypertonic intravenous fluids b. A 76-year-old who is cognitively impaired c. A 36-year-old who is prescribed long-term steroid therapy d. An 83-year-old with congestive heart failure

b. A 76-year-old who is cognitively impaired

A patient comes to the clinic complaining of frequent, watery stools for the last 2 days. Which action should the nurse take first? Answers: a. Obtain the baseline weight. b. Check the patient's blood pressure. c. Draw blood for serum electrolyte levels. d. Ask about any extremity numbness or tingling.

b. Check the patient's blood pressure.

The nurse had administed 4 oz of orange juice to take an alert patient whose blood glucose was 62 mg/dL. Fifteen minutes later, the blood glucose is 67 mg/dL. Which action should the nurse take next? a. administer PRN glucagon 1 mg IM b. Give the patient 4-6 more oz of orange juice c. have the patient eat some peanut butter with crackers d. notify the health care provider about hypoglycemia

b. Give the patient 4-6 more oz of orange juice

A nurse assesses a client on the medical-surgical unit. Which statement made by the client should alert the nurse to the possibility of hypothyroidism? a. I seem to feel heat more than other people b. I am always tired, even with 12 hours of sleep c. my sister has thyroid problems d. food just does not taste good without a lot of salt

b. I am always tired, even with 12 hours of sleep

The nurse is calculating intake and output on a patient. The patient drinks 150 mL of orange juice at breakfast, voids 125 mL after breakfast, vomits 250 mL of greenish fluid, sucks on 60 mL of ice chips, and for lunch consumes 75 mL of chicken broth. Which totals for intake and output will the nurse document in the patient's medical record? Answers: a. Intake 535; output 125 b. Intake 255; output 375 c. Intake 285; output 375 d. Intake 505; output 125

b. Intake 255; output 375

A nurse provides education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (select all that apply) a. Respiratory Failure b. Kidney Failure c. Cirrhosis d. Stroke e. Blindness

b. Kidney Failure d. Stroke e. Blindness

What insulin can be mixed with lantus (insulin glargine)? a. Rapid acting (Humalog) b. Nothing c. Short acting (regular) d. Intermediate acting (NPH)

b. Nothing

A nurse cares for a client who has a serum potassium of 7.5 mEq/L and is exhibiting cardiovascular changes. Which prescription should the nurse implement first? Answers: a. Prepare to administer sodium polystyrene sulfate (Kayexalate) 15 g by mouth. b. Prepare to administer dextrose 20% and 10 units of regular insulin IV push. c. Prepare the client for hemodialysis treatment. d. Provide a heart healthy, low-potassium diet.

b. Prepare to administer dextrose 20% and 10 units of regular insulin IV push.

A patient is admitted to the emergency department with severe fatigue and confusion. Laboratory studies are done. Which laboratory value will require the most immediate action by the nurse? Answers: a. Serum potassium is 5.1 mEq/L. b. Serum calcium is 18 mg/dL. c. Serum sodium is 136 mEq/L. d. Arterial oxygen saturation is 91%.

b. Serum calcium is 18 mg/dL.

The health care provider has ordered a hypotonic intravenous (IV) solution to be administered. Which IV bag will the nurse prepare? Answers: a. Dextrose 5% in Lactated Ringer's b. 0.9% sodium chloride c. 0.45% sodium chloride d. Lactated Ringer's

c. 0.45% sodium chloride

The patient who was admitted with DKA secondary to a urinary tract infection has been weaned off an insulin drip 30 mins ago. The patient reports feeling lightheaded and sweaty. What action should the nurse take first? a. administer 1 mg glucagon subq b. assess glucose reading using a finger stick c. infuse dextrose 50% by slow IV push d. have the patient drink 4 ounces of orange juice

b. assess glucose reading using a finger stick

after teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. at my age, I should continue to see the opthalmogist as I usually do b. diabetes can cause blindness, so I should see the optimalmologist yearly c. I will see the eye doctor when I have a vision problem and yearly after age 40 d. my vision will change quickly, I should see the eye doctor twice a year

b. diabetes can cause blindness, so I should see the ophthalmologist yearly

A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in the client's teaching (select all that apply) a. treat any blisters with Epsom salts b. do not walk around barefoot c. wash your feet every other day d. soak your feet in a tub every evening e. trim toenails straight across with a nail clipper

b. do not walk around barefoot e. trim toenails straight across with a nail clipper

Which teaching is a priority for the client with gastroesophageal reflux? a. "You may include orange or tomato juice with your breakfast." b. "Eat a small evening snack 1 to 2 hours before bed." c. "Eat four to six small meals each day." d. "Drink carbonated beverages between meals only."

c. "Eat four to six small meals each day."

For the client diagnosed with hepatitis A asking how the infection may have been contracted, which response by the nurse is correct? a. "You have had Epstein-Barr virus before, and hepatitis A can co-infect you." b. "Some medications have been known to induce hepatitis A." c. "You may have been exposed through contaminated shellfish." d. "You may have been infected through a recent blood transfusion."

c. "You may have been exposed through contaminated shellfish."

After change-of-shift report, which patient will the nurse assess first? a. A 30-year-old woman whose gastrostomy tube is plugged after crushed medications were administered. b. A 30-year-old man with 4+ generalized pitting edema and severe protein-calorie malnutrition c. A 40-year-old man with continuous enteral feedings who has developed pulmonary crackles d. A 40-year-old woman whose parenteral nutrition infusion bag has 30 minutes of solution left

c. A 40-year-old man with continuous enteral feedings who has developed pulmonary crackles

Which laboratory data does the nurse correlate with advanced disease in the client with cirrhosis? a. Decreased urine sodium b. Decreased lactate dehydrogenase level c. Elevated serum ammonia level d. Elevated serum protein level

c. Elevated serum ammonia level

The nurse implements which action for the client admitted to the hospital who is jaundiced and suspected of having contracted hepatitis B? a. Assisting the client with ambulation to prevent thrombus formation b. Medicating the client with PRN prochlorperazine maleate (Compazine) to relieve nausea c. Encouraging bedrest during this period d. Placing the client on a clear liquid diet to reduce the workload of the liver

c. Encouraging bedrest during this period

The nurse should suspects which complication in a client with Barrett's esophagus who is complaining of dysphagia? a. Achalasia b. Paraesophageal hernia c. Esophageal stricture d. Oropharyngeal dysphagia

c. Esophageal stricture

The nurse notes a bulge in the client's groin that is present when the client stands and disappears when the client lies down. Which conclusion does the nurse draw from these assessment findings? a. The client has an indirect umbilical hernia. b. The client has a strangulated ventral hernia. c. The client has a reducible inguinal hernia. d. The client has an incarcerated femoral hernia.

c. The client has a reducible inguinal hernia.

A patient presents to the emergency department with reports of vomiting and diarrhea for the past 48 hours. The health care provider orders isotonic intravenous (IV) therapy. Which IV will the nurse prepare? Answers: a. 3% sodium chloride b. 0.225% sodium chloride c. 0.9% sodium chloride d. 0.45% sodium chloride

c. 0.9% sodium chloride

A patient is to receive 1000 mL of 0.9% sodium chloride intravenously at a rate of 125 mL/hr. The nurse is using microdrip (60 drops/mL) tubing. Which rate will the nurse calculate for the minute flow rate (drops/min)? Answers: a. 24 drops/min b. 150 drops/min c. 125 drops/min d. 12 drops/min

c. 125 drops/min

Which statement by the patient indicates a need for additional instruction in administering insulin? a. I do not need to aspirate the plunger to check for blood before injecting insulin b. I should draw up the regular insulin first after injecting air into the NPH bottle c. I need to rotate injection sites among my arms, legs, and abdomen each day d. I can buy the 0.5 mL syringes because the line markings will be easier to see

c. I need to rotate injection sites among my arms, legs, and abdomen each day

A nurse is caring for a patient with peripheral intravenous (IV) therapy. Which task will the nurse assign to the nursing assistive personnel? Answers: a. Starting peripheral intravenous therapy b. Changing a peripheral intravenous dressing c. Recording intake and output d. Regulating intravenous flow rate

c. Recording intake and output

The nurse is evaluating the effectiveness of the intravenous fluid therapy in a patient with hypernatremia. Which finding indicates goal achievement? Answers: a. Large amounts of emesis and diarrhea decrease. b. Urine output increases to 150 mL/hr. c. Serum sodium concentration returns to normal. d. Systolic and diastolic blood pressure decrease.

c. Serum sodium concentration returns to normal.

Which assessment finding will the nurse expect for a patient with the following laboratory values: sodium 145 mEq/L, potassium 4.5 mEq/L, calcium 4.5 mg/dL? Answers: a. Weak quadriceps muscles b. Decreased deep tendon reflexes c. Tingling of extremities with possible tetany d. Light-headedness when standing up

c. Tingling of extremities with possible tetany

The health care provider asks the nurse to monitor the fluid volume status of a heart failure patient and a patient at risk for clinical dehydration. Which is the most effective nursing intervention for monitoring both of these patients? Answers: a. Ask the patients to record their intake and output. b. Measure the patients' blood pressures every 4 hours. c. Weigh the patients every morning before breakfast. d. Assess the patients for edema in extremities.

c. Weigh the patients every morning before breakfast.

Type 2 diabetes: a. is unaffected by weight loss b. is associated with excess sugar c. associated with insulin resistance d. cannot be controlled by nutrition therapy

c. associated with insulin resistance

Which statement by a nurse to a patient newly diagnosed with type 2 diabetes is correct? a. Insulin is not used to control blood glucose in patients with type 2 diabetes b. complications of type 2 diabetes are less serious than type 1 c. changes in diet and exercise may control blood glucose levels in type 2 d. type 2 diabetes is usually diagnosed when the patient is admitted with a hyperglycemic coma

c. changes in diet and exercise may control blood glucose levels in type 2

A nurse assesses a client who has a 15 year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a. document the finding in the client's chart b. assess tactile sensation in the client's hands c. examine the client's feet for signs of injury d. notify the health care provider

c. examine the client's feet for signs of injury

A person with type 2 diabetes is scheduled for a follow-up visit in the clinic several months from now. Which test will the nurse schedule to evaluate the effectiveness of treatment for the patient a. Fasting blood glucose level (FBGL) b. Urine dipstick for glucose c. glycosylated hemoglobin level (A1C) d. oral glucose tolerance test (OGTT)

c. glycosylated hemoglobin level (A1C)

A 54 year old patient is admitted with DKA. Which admission order should the nurse implement first? a. start a regular insulin infusion at 0.1 units/kg/hr b. administer regular insulin 10 U by IV push c. infuse 1 L of normal saline per hour d. give sodium bicarbonate 50 mEq IV push

c. infuse 1 L of normal saline per hour

A 27- year-old patient admitted with DKA has a serum glucose level of 732 mg/dL and serum potassium level of 3.1 mEq/L. Which action prescribed by the health care provider should the nurse take first? a. obtain urine glucose and ketone levels b. administer IV potassium supplements c. place the patient on a cardiac monitor d. start and insulin infusion at 0.1 units/kg/hr

c. place the patient on a cardiac monitor

The nurse is providing discharge teaching for a client who has peptic ulcer disease caused by Helicobacter pylori infection. Which statement by the client indicates that additional teaching is needed? a. "I will take a multivitamin every morning with breakfast." b. "I will go to my tai chi class to wind down after a busy day." c. "I will avoid drinking coffee, even if it is decaffeinated." d. "I will take my antibiotic every day until my heartburn is gone."

d. "I will take my antibiotic every day until my heartburn is gone."

The nurse correlates decreased hepatic synthesis of which substance in the client who develops ascites? a. Bile b. Carbohydrates c. Glucose d. Albumin

d. Albumin

The nurse is caring for a client with acute pancreatitis. Which nursing intervention will best reduce discomfort for the client? a. Administering 2L oxygen via nasal cannula b. Providing small frequent feedings, with no concentrated sweets c. Placing the client in a semi-Fowler's position at 30 degrees elevation d. Maintaining NPO status for the client with IV fluids

d. Maintaining NPO status for the client with IV fluids

A patient hospitalized with chronic heart failure eats only about 50% of each meal and reports "feeling too tired to eat." Which action should the nurse take first? a. Teach the patient about the importance of good nutrition. b. Consult with the health care provider about providing parenteral nutrition (PN). c. Obtain an order for enteral feedings of liquid nutritional supplements. d. Serve multiple small feedings of high-calorie, high-protein foods.

d. Serve multiple small feedings of high-calorie, high-protein foods.

The nurse is caring for an anorexic client who is severely malnourished. A nasogastric feeding tube is inserted and tube feedings are started. Which laboratory finding is the best indication that the client's nutritional status is improving? a. The client's sodium has risen from 130 to 144 mg/dL. b. The client's blood urea nitrogen (BUN) level has dropped from 15 to 11 mg/dL. c. The client's creatinine has dropped from 1.9 to 0.5 mg/dL. d. The client's prealbumin level has risen from 9 to 13 mg/dL.

d. The client's prealbumin level has risen from 9 to 13 mg/dL.

The nurse will anticipate preparing a 71-year-old female patient who is vomiting "coffee-ground" emesis for a. gastric analysis. b. angiography. c. barium studies. d. endoscopy.

d. endoscopy.

Development of ascites in clients who have cirrhosis is related to: a. excess fat intake. b. excess intake of sodium. c. iron deficiency. d. protein deficiency.

d. protein deficiency.

A patient receives aspart (Novalog) insulin at 8:00 A.M. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia? a. 2:00 p.m. b. 4:00 p.m. c. 12:00 a.m. d. 10:00 a.m.

d. 10:00 a.m.

A nurse prepares to administer prescribed regular and NPH insulin. Place the nurse's actions in the correct order to administer these medications. 1. Inspect bottle for expiration dates 2. gently roll the bottle between your hands 3. wash your hands 4. Inject air into the regular insulin 5. withdraw the NPH insulin 6. withdraw the regular insulin 7. inject air into the NPH bottle 8. clean rubber stoppers with an alcohol swab a. 1, 3, 8, 2, 4, 6, 7, 5 b. 8, 1, 3, 2, 4, 6, 7, 5 c. 2, 3, 1, 8, 7, 5, 4, 6 d. 3, 1, 2, 8, 7, 4, 6, 5

d. 3, 1, 2, 8, 7, 4, 6, 5

A nurse is caring for an older adult client who is admitted with moderate dehydration. Which intervention should the nurse implement to prevent injury while in the hospital? Answers: a. Assess urine color, amount, and specific gravity each day. b. Ask family members to speak quietly to keep the client calm. c. Encourage the client to drink at least 1 liter of fluids each shift. d. Dangle the client on the bedside before ambulating.

d. Dangle the client on the bedside before ambulating.

A nurse is evaluating a client who is being treated for dehydration. Which assessment result should the nurse correlate with a therapeutic response to the treatment plan? Answers: a. Increased respiratory rate from 12 breaths/min to 22 breaths/min b. Increased urine specific gravity from 1.012 to 1.030 g/mL c. Decreased skin turgor (tenting) on the client's posterior hand and forehead d. Decreased orthostatic light-headedness and dizziness

d. Decreased orthostatic light-headedness and dizziness

A nurse assesses a client who is admitted for treatment of fluid overload. Which manifestations should the nurse expect to find? (Select all that apply.) Answers: a. Warm and pink skin b. Skeletal muscle weakness c. Distended neck veins d. Increased pulse rate e. Decreased blood pressure

d. Increased pulse rate b. Skeletal muscle weakness c. Distended neck veins

A nurse cares for a client who has hypothyroidism as a result of a total thyroidectomy. The client asks, "How long will I need to take this thyroid medication?" How should the nurse respond? a. Thyroiditis is cured with antibiotics. Then you will not need the thyroid medication b. You will need to take the thyroid medication until the goiter is completely gone c. When blood tests indicate normal thyroid function, you can stop taking the medication d. You will need thyroid pills for life because your thyroid will not start working again

d. You will need thyroid pills for life because your thyroid will not start working again

Which information will the nurse include in teaching a female patient who has peripheral arterial disease, type 2 diabetes, and sensory neuropathy of the feet and legs a. use callus remover for corns and calluses b. soak feet in warm water for an hour each day c. set heating pads on a low temperature d. choose flat-soled leather shoes

d. choose flat-soled leather shoes

A standard blood test that is used to evaluate long-term management and control in patients who have diabetes is a. glucose tolerance test b. plasma glucose level c. self-monitoring of blood glucose d. glycated hemoglobin level

d. glycated hemoglobin level

A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this client's plan of care to delay the onset of microvascular and macrovascular complications? a. limit your intake of protein to prevent DKA b. prevent hypoglycemia by eating a bedtime snack c. restrict your fluid intake to no more than 2 liters a day d. maintain tight glycemic control and prevent hyperglycemia

d. maintain tight glycemic control and prevent hyperglycemia

A common symptom among people with undiagnosed type 2 diabetes is a. weight loss b. night sweats c. jaundice d. poor wound healing

d. poor wound healing

Type 1 diabetes is characterized by: a. a strong relationship to obesity b. slow development in older adults c. infrequent occurence of DKA d. rapid development before age 40

d. rapid development before age 40

A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this client's teaching to prevent injury? a. rotate your insulin sites every week b. check your blood glucose before each meal c. examine your feet using a mirror every day d. use a bath thermometer to test the water temperature

d. use a bath thermometer to test the water temperature

A nurse cares for a client who has a family history of diabetes mellitus. The client states, "My father has type 1 diabetes mellitus. Will I develop this disease as well?" How should the nurse respond? a. Female children do not develop the disease, but male children will. b. no genetic risk is associated with the development of type 1 diabetes c. the risk for becoming diabetic is 50% because of how it is inherited d. your risk of diabetes is higher than the general population, but it may not occur

d. your risk of diabetes is higher than the general population, but it may not occur