med surge exam 2
a nurse is caring for a client with type 1 diabetes mellitus who reports feeling shaky and having palpitations. when the nurse finds the clients blood glucose to be 48 mg/dL on the glucometer, he should give the client which of the following? a graham crackers b 1 tsp sugar c 4 oz diet soda d 4 oz skim milk
after establishing that the client has hypoglycemia, the nurse should give the client about 15 g or rapid acting, concentrated carbohydrate, such as 4 oz of fruit juice, 8 oz of skim milk 3 tsp of sugar or honey, 3 graham crackers, or commercially prepared glucose tablets. the nurse should recheck the clients blood glucose level in 15 min.
which of the following statements regarding peripheral neuropathy is accurate? a it is a disorder that only affects the peripheral nervous system b it can be easily cured with OTC pain medication c it is a rare condition that primarily affects elder individuals d it can Be caused by a variation of factors, including diabetes, alcoholism and chemotherapy
d it can Be caused by a variation of factors, including diabetes, alcoholism and chemotherapy
a nurse is caring for an adolescent client who has a long history of diabetes mellitus and is being admitted to the ED confused, flushed, and with an acetone odor on the breath. DKA is suspected. The nurse should anticipate using which of the following types of insulin to treat this client? a NPH insulin b insulin glargine c insulin detemir d regular insuline
regular insulin is classified as a short acting insulin. it can be given intravenously with an onset of action of less than 30 min. this is the insulin that is most appropriate in emergency situations of sever hyperglycemia or DKA.
a nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. after administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times? a 0720 b 0730 c 0745 d 0815
regular insulin should be given 20 to 30 minutes before eating because he onset of action is 30 minute. there are circumstance when this lag time guide can be adjusted.
a nurse is assessing a client who is receiving one unit of the packed RBC's to treat intraoperative blood loss. the client reports chills and back pain, and the clients blood pressure is 80/64 mm Hg. which of the following actions should the nurse take first? a. stop the infusion of blood b. inform the provider c. obtain a urine specimen d. notify the laboratory
the client is experiencing an acute intravascular hemolytic transfusion reaction. the greatest risk to this client is injury from receiving additional blood; therefore, the first action the nurse should take is to stop the infusion of blood.
a nurse is caring for an older adult client who has RA and is taking aspirin 650 mg every 4 hours (an NSAID). which of the following diagnostic tests should the nurse monitor to evaluate the effectiveness fo this medication? a WBC count b rheumatoid factor (RF) c antinuclear antibody (ANA) d erythrocyte sedimentation rate (ESR)
RA is a chronic inflammatory disease. ESR is useful in detecting and monitoring tissue inflammation in clients with RA. As the disease improves the ESR decreases.
a nurse is caring for a client who has type 1 diabetes mellitus. the nurse misread the clients 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 clients breakfast. which of the following actions is the nurses priority? a. give the client 15 to 20 g of carbohydrate b monitor the client for hypoglycemia c complete an incident report d notify the nurse manager
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 clients 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 teaching a client who has rheumatoid arthritis about self care strategies for managing the disease. which of the following activities should the nurse include in the teaching? a press water from a sponge rathe than wringing it out b turn doorknobs using a clockwise motion c finish weekly household tasks within 1 to 2 days d. engage in repetitive tasks, even when joints are inflamed, to keep the joints mobile
the nurse should instruct the client to modify fine motor activities, such as wringing out a sponge, by suing larger joints or body surfaces, such as the palm of the hand, to substitute for smaller ones.
a nurse is caring for client who is 1 day postoperative following a subtotal thyroidectomy. the client reports a tingling sensation in the hands, the soles of the feet and around the lips. for which of the following findings should the nurse assess the client? a. chvosteks sign b babinskis sign c brudzinski sign d kerning sign
the nurse should suspect that the client has hypocalcemia, a possible complication following subtotal thyroidectomy. manifestations of hypocalcemia inlaced numbness and tingling in the hands, the soles of the feet, and around the lips, typically appearing between 24 and 48 hours after surgery. to elicit chvosteks sign the nurse should tap the clients fact at point just below and in front of the ear. a positive response would be twitching to the ipsilateral (same side only) facial muscles, suggesting neuromuscular excitability due to hypocalcemia.
a nurse is planning to provide discharge teaching for a client who has hearing loss. which of the following actions should the nurse plan to take? a. face the client while talking b.dim the lights in the clients room c. increase the rate of speech when talking with the client d. answer clients questions using medicinal terminology
to facilitate communication with the client who has hearing loss, the nurse should face the client while speaking. other actions the nurse can take to facilitate communication are to provide a well lit environment, ensure any assistive devices used by the client are present and in use, and decrease the noise level in the environment.