MedSurg Exam 2 Practice Questions
Hypoglycemia
A client with diabetes mellitus is receiving an oral antidiabetic agent. The nurse observes for which condition when caring for this client?
Acute glomerulonephritis
A history of infection specifically caused by group A beta-hemolytic streptococci is associated with which disorder?
Cover the protruding coils of intestines with sterile dressings moistened with sterile saline solution.
A nursing measure for evisceration is to:
maintaining pulmonary ventilation
The primary objective in the immediate postoperative period is
Transrectal ultrasonography
Which is the procedure of choice for men with recurrent or complicated UTIs?
Explain that the client's physical changes are a result of excessive corticosteroids
A nurse should perform which intervention for a client with Cushing's syndrome?
Dysfunction of the thyroid gland itself
A patient has been diagnosed with thyroidal hypothyroidism. The nurse knows that this diagnosis is consistent with which of the following?
"I'll be sleepy but able to respond to your questions." With moderate sedation, the patient can maintain a patent airway (i.e., doesn't need a tube to help breathing), retain protective airway reflexes, and respond to verbal and physical stimuli. The patient is not unconscious with moderate sedation.
After teaching a patient scheduled for ambulatory surgery using moderate sedation, the nurse determines that the patient has understood the teaching based on which of the following statements?
at least three times per week
During a class on exercise for clients with diabetes mellitus, a client asks the nurse educator how often to exercise. To meet the goals of planned exercise, the nurse educator should advise the client to exercise:
heat intolerance and systolic hypertension
Hyperthyroidism is caused by increased levels of thyroxine in blood plasma. A client with this endocrine dysfunction experiences:
Perform meticulous perineal care daily with soap and water Cleanliness of the area will reduce potential for infection. Strict aseptic technique must be used when inserting a urinary bladder catheter. The nurse must maintain a closed system and use the catheter's port to obtain specimens. The catheter bag must never be placed on the client's abdomen unless it is clamped because it may cause urine to flow back from the tubing into the bladder.
If an indwelling catheter is necessary, which nursing intervention should be implemented to prevent infection?
the client's cultural beliefs A client's cultural beliefs may influence whether medical and nursing interventions are acceptable or unacceptable to the client
In developing the plan of care for the intraoperative client, the nurse recognizes that it is essential to consider:
Provide several small meals each day for the patient.
In planning the care of a patient who has hyperthyroidism, the nurse has identified the nursing diagnosis of altered nutrition: less than body requirements. What intervention is the best response to this diagnosis?
Discouraging caffeine intake Strategies for preventing urinary tract infection include proper perineal hygiene, increased fluid intake, avoiding urinary tract irritants (including caffeine), and establishing a frequent voiding regimen
Nursing management of the client with a urinary tract infection should include:
Review the scheduled procedure, site, and client.
Once the operating team has assembled in the room, the circulating nurse calls for a "time out." What action should the nurse take during the time out?
hypertension The nurse should monitor for hypotension, not hypertension, during the treatment related to the removal of fluid. Muscle cramping may occur late in dialysis as fluid and electrolytes rapidly leave the extracellular space. Dysrhythmias may result from electrolyte and pH changes or removal of antiarrhythmic medications. Air embolism is rare, but could occur if air enters the vascular system
The nurse monitors the client for potential complications during dialysis but recognizes NOT to monitor for...
Coordinating the surgical team
What are the circulating nurse's responsibilities, in contrast to the scrub nurse's responsibilities?
Rapid-acting Humalog is a rapid-acting insulin. NPH is an intermediate-acting insulin. A short-acting insulin is Humulin-R. An example of a long-acting insulin is Glargine (Lantus).
Lispro (Humalog) is an example of which type of insulin?
Phenazopyridine
Which medication may be ordered to relieve discomfort associated with a urinary tract infection?
Patient's eating and sleeping habits
Which of the following factors should the nurse take into consideration when planning meals and selecting the type and dosage of insulin or oral hypoglycemic agent for an elderly patient with diabetes mellitus?
Adrenal
Clients who have received corticosteroids preoperatively are at risk for which type of insufficiency?
Initiation Period of AKI
Period of AKI which begins with the initial insult and ends when oliguria develops
Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Diabetes mellitus is more common in Hispanics and Blacks than in Whites. Only about one-third of clients with diabetes mellitus are older than age 60 and 85% to 90% have type 2. At least 80% of clients diagnosed with type 2 diabetes mellitus are obese
An obese Hispanic client, age 65, is diagnosed with type 2 diabetes. Which statement about diabetes mellitus is true?
Recovery period of AKI
Final period of AKI which signals the improvement of renal function and may take 6 to 12 months; BUN+creatinine down, GFR up
Perioperative Perioperative period includes the preoperative, intraoperative, and postoperative phases
Regarding the surgical client, which phase refers to the period of time that spans the entire surgical experience?
maintain the safety of the client. Verification of the identification of the client, procedure, and operative site are essential to maintain the safety of the client
The nurse understands that the purpose of the "time out" is to:
Preparing the sterile instruments for the surgical procedure
The scrub nurse is responsible for:
Increased BUN The intrarenal category of acute kidney injury (AKI) encompasses an increased BUN, increased creatinine, a low-normal specific gravity of urine, and increased urine sodium.
What is a characteristic of the intrarenal category of acute kidney injury (AKI)?
Proteinuria
What is a hallmark of the diagnosis of nephrotic syndrome?
Dehydration The diuretic phase of acute renal failure is characterized by increased urine output, hypotension, and dehydration
The nurse expects which of the following assessment findings in the client in the diuretic phase of acute renal failure?
anemia Anemia, hyperkalemia, metabolic acidosis, and hyperphosphatemia occur during chronic glomerulonephritis
A change that occurs during chronic glomerulonephritis is termed
4
A client has been experiencing a decrease in serum calcium. After diagnostics, the physician proposes the calcium level fluctuation is due to altered parathyroid function. What is the typical number of parathyroid glands?
Recent history of streptococcal infection
A nurse is reviewing the history of a client who is suspected of having glomerulonephritis. Which of the following would the nurse consider significant?
"I'm thirsty all the time. I just can't get enough to drink." Classic signs and symptoms of diabetes mellitus are polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive appetite).
A client is evaluated for type 1 diabetes. Which client comment correlates best with this disorder?
Glucocorticoids
A client is having chronic pain from arthritis. What type of hormone is released in response to the stress of this pain that suppresses inflammation and helps the body withstand stress?
Granulocytopenia
Antithyroid medications are not generally recommended for elderly patients because of which side effect?
Immunocompromise Factors that contribute to urinary tract infection in older adults include immunocompromise, high incidence of chronic illness, immobility, frequent use of antimicrobial agents, incomplete emptying of the bladder, and obstructed urine flow.
Which factor contributes to UTI in older adults?
Glucagon Glucagon is a hormone released by the alpha islet cells of the pancreas that raises blood glucose levels by stimulating glycogenolysis (the breakdown of glycogen into glucose in the liver).
Which hormone would be responsible for increasing blood glucose levels by stimulating glycogenolysis?
Serum glucose The nurse would evaluate serum and urine levels of glucose because diabetes is the primary cause of renal failure.
Based on her knowledge of the primary cause of end-stage renal disease, the nurse knows to assess the most important indicator. What is that indicator?
Measurement of blood hormone levels A thyroid panel measures the blood hormone levels of TSH, T3, and T4. It is a blood test.
A client is scheduled for a thyroid panel. The nurse understands that this test would involve which of the following?
Uremia Uremia is the buildup of nitrogenous wastes in the blood, evidenced by an elevated blood urea nitrogen and creatine levels. Uremia, anemia, and acidosis are consistent clinical manifestations of chronic renal failure.
Which clinical finding should a nurse look for in a client with chronic renal failure?
Hypokalemia and hypoglycemia Blood glucose needs to be monitored in clients receiving IV insulin because of the risk of hyperglycemia or hypoglycemia.
Which combination of adverse effects should a nurse monitor for when administering IV insulin to a client with diabetic ketoacidosis?
Computed tomography CT or magnetic resonance imaging is used to diagnose the presence and extent of pituitary tumors.
Which diagnostic test is done to determine a suspected pituitary tumor?
Health care systems The health care system consists of structural data elements and focuses on clinical processes and outcomes.
Which domain of perioperative nursing practice focuses on clinical processes and outcomes?
Void immediately after sexual intercourse.
The nurse who teaches a client about preventing recurrent urinary tract infections would include which statement?
Using sterile technique during the dressing change
Which intervention is essential when performing dressing changes on a client with a diabetic foot ulcer?
Stress Stress incontinence may occur with sneezing, coughing, or changing position
Which type of incontinence refers to involuntary loss of urine through an intact urethra as a result of a sudden increase in intra-abdominal pressure?
Urinary calculi Symptoms of a kidney or ureteral stone vary with size, location, and cause. Small stones may pass unnoticed; however, sudden, sharp, severe flank pain that travels to the suprapubic region and external genitalia is the classic symptom of urinary calculi.
A client comes to the emergency department complaining of a sudden onset of sharp, severe flank pain. During the physical examination, the client indicates that the pain, which comes in waves, travels to the suprapubic region. He states, "I can even feel the pain at the tip of my penis." Which of the following would the nurse suspect?
Painless, gross hematuria Although flank pain may occur, the painless, gross hematuria is characteristic of bladder cancer.
A 64-year-old man is seeing his urologist for an annual check-up, post prostatectomy. The health care provider is concerned with the symptom he finds because it is considered diagnostic for bladder cancer. Which of the following signs/symptoms is diagnostic for bladder cancer?
Decreased lean tissue mass Elderly patients require lower doses of anesthetic agents because of decreased tissue elasticity and reduced lean tissue mass.
A 70-year-old patient who is to undergo surgery arrives at the operating room (OR). The nurse, when reviewing the patient's medical record, understands that this patient will require a lower dose of anesthetic agent because of which of the following?
Appropriately position the client using adequate padding and support. Adequate padding and support should be used to prevent positioning injuries. Older adults have lower bone mass, which increases the risk of intraoperative positioning injuries.
A 78-year-old client is undergoing surgery to repair a right hip fracture. What nursing action is appropriate during the intraoperative phase?
Skin breakdown Skin breakdown is an important nursing consideration when providing care for all surgical patients. However, older adults face an increased risk of this problem due to age-related changes to the integumentary system.
A 79-year-old man is scheduled for surgical repair of an inguinal hernia. In light of this patient's age, the nurse will prioritize nursing interventions aimed at preventing:
Urine output of 250 ml/24 hours
A client admitted with a gunshot wound to the abdomen is transferred to the intensive care unit after an exploratory laparotomy. IV fluid is being infused at 150 mL/hour. Which assessment finding suggests that the client is experiencing acute renal failure (ARF)?
Urge Urge incontinence occurs when the client experiences the sensation to void but cannot control voiding in time to reach a toilet. Stress incontinence occurs when the client has an involuntary loss of urine that results from a sudden increase in intra-abdominal pressure. Overflow incontinence occurs when the client experiences an involuntary loss of urine related to an overdistended bladder; the client voids small amounts frequently and dribbles. Functional incontinence occurs when the client has function of the lower urinary tract but cannot identify the need to void or ambulate to the toilet
A client comes to the clinic for a follow-up visit. During the interview, the client states, "Sometimes when I have to urinate I can't control it, and do not reach the bathroom in time." The nurse suspects that the client is experiencing which type of incontinence?
Acute pain Ureterolithiasis typically causes such acute, severe pain that the client can't rest and becomes increasingly anxious. Therefore, the nursing diagnosis of Acute pain takes highest priority.
A client comes to the emergency department complaining of severe pain in the right flank, nausea, and vomiting. The physician tentatively diagnoses right ureterolithiasis (renal calculi). When planning this client's care, the nurse should assign the highest priority to which nursing diagnosis?
Increase carbohydrates and limit protein intake. Calories are supplied by carbohydrates and fat to prevent wasting. Protein is restricted because the breakdown products of dietary and tissue protein (urea, uric acid, and organic acids) accumulate quickly in the blood
A client has end-stage renal failure. Which of the following should the nurse include when teaching the client about nutrition to limit the effects of azotemia?
7 to 10 days Aspirin, a common OTC medication that inhibits platelet aggregation, should be prudently discontinued 7 to 10 days before surgery; otherwise, the client may be at increased risk for bleeding.
A client having a surgical procedure takes aspirin 325 mg daily for prevention of platelet aggregation. When should the client stop taking the aspirin before the surgery?
profound neuromuscular irritability. Hypoparathyroidism may slow bone resorption, reduce the serum calcium level, and cause profound neuromuscular irritability (as evidenced by tetany)
A client is admitted to an acute care facility with a tentative diagnosis of hypoparathyroidism. The nurse should monitor the client closely for the related problem of
Serum potassium level of 5.8 mEq/L Addison's disease decreases the production of aldosterone, cortisol, and androgen, causing urinary sodium and fluid losses, an increased serum potassium level, and hypoglycemia.
A client is admitted to the health care facility for evaluation for Addison's disease. Which laboratory test result best supports a diagnosis of Addison's disease?
Regular Regular insulin is administered intravenously to treat DKA. It is added to an IV solution and infused continuously. Glargine, NPH, and Lente are only administered subcutaneously.
A client is admitted to the unit with diabetic ketoacidosis (DKA). Which insulin would the nurse expect to administer intravenously? a) Regular b)Glargine c)NPH d)Lente
Start IV fluids with a normal saline solution bolus followed by a maintenance dose. The client is in prerenal failure caused by hypovolemia. I.V. fluids should be given with a bolus of normal saline solution followed by maintenance I.V. therapy. This treatment should rehydrate the client, causing his blood pressure to rise, his urine output to increase, and the BUN and creatinine levels to normalize.
A client is admitted with nausea, vomiting, and diarrhea. His blood pressure on admission is 74/30 mm Hg. The client is oliguric and his blood urea nitrogen (BUN) and creatinine levels are elevated. The physician will most likely write an order for which treatment?
"As long as I have one normal kidney, I should be fine." Polycystic kidney disease is characterized by the formation of multiple cysts on both kidneys. Polycystic kidney disease is inherited as an autosomal dominant trait. The fluid-filled cysts can cause great enlargement of the kidneys and interfere with kidney function, which can eventually lead to renal failure.
A client is diagnosed with polycystic kidney disease and requires teaching on the management of the disorder. Which statement made by the client indicates a need for further teaching?
Donors are selected from compatible living or deceased donors. Donors are selected from compatible living donors. Donors do not have to be relatives as long as they are compatible. Potential donors with a history of hypertension, malignant disease, or diabetes are excluded from donation. Each local hospital does not have its own transplant list, instead the client will be placed on a national computerized transplant waiting list.
A client is in end-stage chronic renal failure and is being added to the transplant list. The nurse explains to the client how donors are found for clients needing kidneys. Which statement is accurate?
Scrub nurse The scrub nurse is sterile and assists the surgical team by handing instruments to the surgeon, preparing sutures, receiving specimens to be sent to the lab, and counting sponges and needles. The circulating nurse is not sterile and obtains and opens sterile equipment, adjusts lights, and keeps records. The first assistant is involved with the client's preoperative care. The certified registered nurse anesthetist assists in the client's anesthesia.
A client is placed on the operating room table for the surgical procedure. Which surgical team member is responsible for handing sterile instruments to the surgeon and assistants?
Moon face Clients who are receiving long-term high-dose corticosteroid therapy often develop a cushingoid appearance, manifested by facial fullness and the characteristic moon face. They also may exhibit weight gain, peripheral edema, and hypertension due to sodium and water retention. The skin is usually thin, and ruddy.
A client is receiving long-term treatment with high-dose corticosteroids. Which of the following would the nurse expect the client to exhibit?
Tracheostomy set After a subtotal thyroidectomy, swelling of the surgical site (the tracheal area) may obstruct the airway. Therefore, the nurse should keep a tracheostomy set at the client's bedside in case of a respiratory emergency
A client is returned to his room after a subtotal thyroidectomy. Which piece of equipment is most important for the nurse to keep at the client's bedside?
To prevent cerebrospinal fluid (CSF) leakage The client receiving a subarachnoid block requires special positioning to prevent CSF leakage and headache and to ensure proper anesthetic distribution
A client is scheduled for a prostatectomy, and the anesthesiologist plans to use a spinal (subarachnoid) block during surgery. In the operating room, the nurse positions the client according to the anesthesiologist's instructions. Why does the client require special positioning for this type of anesthesia?
Magnetic resonance imaging (MRI)
A client is suspected to have a pituitary tumor due to signs of diabetes insipidus. What initial test does the nurse help to prepare the client for?
Lessen workload on the kidneys Although some protein is necessary for complete nutrition, clients with decreased renal function have difficulty excreting waste products from protein metabolism.
A client with decreased renal function is to receive a low-protein diet. The client asks the nurse why he needs this type of diet. The nurse would incorporate which reason into the response?
"Ketones will tell us if your body is using other tissues for energy." The nurse should tell the client that ketones are a byproduct of fat metabolism and that ketone testing can determine whether the body is breaking down fat to use for energy.
A client newly diagnosed with diabetes mellitus asks why he needs ketone testing when the disease affects his blood glucose levels. How should the nurse respond?
hyperpituitarism Acromegaly (hyperpituitarism) is a condition in which growth hormone is oversecreted after the epiphyses of the long bones have sealed. A client with acromegaly has coarse features, a huge lower jaw, thick lips, a thickened tongue, a bulging forehead, a bulbous nose, and large hands and feet. When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica are common.
A client presents with a huge lower jaw, bulging forehead, large hands and feet, and frequent headaches. What could be causing this client's symptoms?
This insulin has no peak action and does not cause a hypoglycemic reaction.
A client receives a daily injection of glargine insulin at 7:00 a.m. When should the nurse monitor this client for a hypoglycemic reaction?
Diabetes insipidus (DI) Urine output may be as high as 20 L/24 hours. Urine is dilute, with a specific gravity of 1.002 or less. Limiting fluid intake does not control urine exertion. Thirst is excessive and constant.
A client sustained a head injury when falling off of a ladder. While in the hospital, the client begins voiding large amounts of clear urine and states he is very thirsty. The client states that he feels weak, and he has had an 8-lb weight loss since admission. What should the client be tested for?
glycosylated hemoglobin level Because some of the glucose in the bloodstream attaches to some of the hemoglobin and stays attached during the 120-day life span of red blood cells, glycosylated hemoglobin levels provide information about blood glucose levels during the previous 3 months. Fasting blood glucose and urine glucose levels give information only about glucose levels at the point in time when they were obtained. Serum fructosamine levels provide information about blood glucose control over the past 2 to 3 weeks
A client tells the nurse that she has been working hard for the past 3 months to control her type 2 diabetes with diet and exercise. To determine the effectiveness of the client's efforts, the nurse should check...
Maintain skin and stomal integrity.
A client undergoes surgery to remove a malignant tumor, followed by a urinary diversion procedure. The nurse's postoperative plan of care should include which action?
Turn the client's head completely to one side to prevent aspiration of vomitus into the lungs.
A client vomits postoperatively. What is the most important nursing intervention?
urinary tract infection Signs of a bladder infection include fever, chills, and suprapubic pain
A client who has a history of neurogenic bladder presents with fever, burning, and suprapubic pain. What would the nurse suspect is the problem?
Decrease in the blood flow through the kidneys
A client who suffered hypovolemic shock during a cardiac incident has developed acute renal failure. Which is the best nursing rationale for this complication?
Rapid, thready pulse This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations.
A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level?
Serum osmolarity Serum osmolarity is the most important test for confirming HHNS; it's also used to guide treatment strategies and determine evaluation criteria. A client with HHNS typically has a serum osmolarity of more than 350 mOsm/L.
A client with a tentative diagnosis of hyperosmolar hyperglycemic nonketotic syndrome (HHNS) has a history of type 2 diabetes that is being controlled with an oral diabetic agent, tolazamide. Which laboratory test is the most important for confirming this disorder?
Hypophysectomy The treatment of choice is surgical removal of the pituitary gland (transsphenoidal hypophysectomy) through a nasal approach.
A client with acromegaly has been given the option of a surgical approach or a medical approach. The client decides to have a surgical procedure to remove the pituitary gland. What does the nurse understand this surgical procedure is called?
Pressure on the optic nerve
A client with acromegaly is admitted to the hospital with complaints of partial blindness that began suddenly. What does the nurse suspect is occurring with this client?
A pituitary tumor When the overgrowth is from a tumor, headaches caused by pressure on the sella turcica, a bony depression in which the pituitary gland rests, are common.
A client with acromegaly is complaining of severe headaches. What does the nurse suspect is the cause of the headaches that is related to the acromegaly?
hyponatremia and hyperkalemia. The client's history and presenting symptoms suggest the onset of adrenal crisis. Laboratory findings that support adrenal deficiency and crisis include low serum sodium (hyponatremia) and high serum potassium (hyperkalemia) levels
A client with adrenal insufficiency is gravely ill and presents with nausea, vomiting, diarrhea, abdominal pain, profound weakness, and headache. The client's family reports that the client has been doing strenuous yard work all day and was sweating profusely. Nursing management of this client would include observation for signs of:
fatigue and weakness RBCs carry oxygen throughout the body. Decreased RBC production diminishes cellular oxygen, leading to fatigue and weakness.
A client with chronic renal failure (CRF) has developed faulty red blood cell (RBC) production. The nurse should monitor this client for:
Hyperphosphatemia Osteodystrophy is a condition in which the bone becomes demineralized due to hypocalcemia and hyperphosphatemia.
A client with chronic renal failure complains of generalized bone pain and tenderness. Which assessment finding would alert the nurse to an increased potential for the development of spontaneous bone fractures?
Metformin Metformin is a biguanide and along with the thiazolidinediones (rosiglitazone and pioglitazone) are categorized as insulin sensitizers; they help tissues use available insulin more efficiently. Glyburide and glipizide which are sulfonylureas, and repaglinide, a meglitinide, are described as being insulin releasers because they stimulate the pancreas to secrete more insulin.
A client with diabetes is receiving an oral antidiabetic agent that acts to help the tissues use available insulin more efficiently. Which of the following agents would the nurse expect to administer?
They increase the need for insulin. Insulin requirements increase in response to growth, pregnancy, increased food intake, stress, surgery, infection, illness, increased insulin antibodies, and some medications.
A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin?
Tachycardia
A client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should the nurse recognize as an adverse reaction to the drug?
Risk for infection The peritoneal dialysis catheter and regular exchanges of the dialysis bag provide a direct portal for bacteria to enter the body.
A client with renal failure is undergoing continuous ambulatory peritoneal dialysis. Which nursing diagnosis is the most appropriate for this client?
Sweating, tremors, and tachycardia Sweating, tremors, and tachycardia, thirst, and anxiety are early signs of hypoglycemia.
A client with status asthmaticus requires endotracheal intubation and mechanical ventilation. Twenty-four hours after intubation, the client is started on the insulin infusion protocol. The nurse must monitor the client's blood glucose levels hourly and watch for which early signs and symptoms associated with hypoglycemia?
Finger Even though the fingertips have a higher number of nerve endings, this site provides the most accurate blood sugar reading.
A client with type 1 diabetes mellitus is receiving short-acting insulin to maintain control of blood glucose levels. In providing glucometer instructions, the nurse would instruct the client to use which site for most accurate findings?
Underlying problem of insulin resistance Clients with type 2 diabetes are not offered the option of a pancreas transplant because their problem is insulin resistance, which does not improve with a transplant.
A client with type 2 diabetes asks the nurse why he can't have a pancreatic transplant. Which of the following would the nurse include as a possible reason?
"Make sure to eat enough fiber to prevent constipation." Suggestions to manage urinary incontinence include avoiding constipation such as eating adequate fiber and drinking adequate amounts of fluid.The client should void regularly, approximately every 2 to 3 hours to ensure bladder emptying
A client with urinary incontinence asks the nurse for suggestions about managing this condition. Which suggestion would be most appropriate?
Oliguria During the second phase, the oliguric phase, oliguria occurs. Diuresis occurs during the third or diuretic phase. Acute tubular necrosis (ATN) occurs during the first, or initiation, phase in which reduced blood flow to the nephrons leads to ATN. Restoration of glomerular function, if it occurs, occurs during the fourth, or recovery, phase.
A group of students are reviewing the phases of acute renal failure. The students demonstrate understanding of the material when they identify which of the following as occurring during the second phase?
The participants are unlikely to develop a new onset of type 1 diabetes. Type 1 diabetes usually (but not always) develops in people younger than 20. In older adults, an onset of type 2 is far more common. A significant number of older adults develops type 2 diabetes.
A nurse educator been invited to local seniors center to discuss health-maintaining strategies for older adults. The nurse addresses the subject of diabetes mellitus, its symptoms, and consequences. What should the educator teach the participants about type 1 diabetes?
estrogen and progesterone
A nurse explains the role of the ovaries. Which hormones would be included in that discussion?
Insulin is absorbed more rapidly at abdominal injection sites than at other sites. Subcutaneous insulin is absorbed most rapidly at abdominal injection sites, more slowly at sites on the arms, and slowest at sites on the anterior thigh.
A nurse explains to a client that she will administer his first insulin dose in his abdomen. How does absorption at the abdominal site compare with absorption at other sites?
Need to urinate after engaging in sexual intercourse Measures to prevent cystitis include voiding after sexual intercourse, wearing cotton underwear, urinating every 2 to 3 hours while awake, and taking showers instead of tub baths
A nurse has been asked to speak to a local women's group about preventing cystitis. Which of the following would the nurse include in the presentation?
Encourage use of incentive spirometer every 2 hours.
A nurse identifies a nursing diagnosis of risk for ineffective breathing pattern related to incisional pain and restricted positioning for a client who has had a nephrectomy. Which of the following would be most appropriate for the nurse to include in the client's plan of care?
Increased urine output Glucose supplies most of the calories in TPN; if the glucose infusion rate exceeds the client's rate of glucose metabolism, hyperglycemia arises. When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
Increased urine output When the renal threshold for glucose reabsorption is exceeded, osmotic diuresis occurs, causing an increased urine output.
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia?
An irregular apical pulse Because Cushing's syndrome causes aldosterone overproduction, which increases urinary potassium loss, the disorder may lead to hypokalemia. Therefore, the nurse should immediately report signs and symptoms of hypokalemia, such as an irregular apical pulse, to the physician.
A nurse is assessing a client with Cushing's syndrome. Which observation should the nurse report to the physician immediately?
Weight loss, nervousness, and tachycardia
A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?
wound healing In caring for a postoperative client, the nurse is correct to correlate hyperglycemia with an increased risk of surgical incision infections and delayed wound healing. Strict control of glycemic blood levels at the therapeutic range of 80-110 mg/dL would reduce this risk factor
A nurse is assessing a postoperative client with hyperglycemic blood glucose levels. Which post-surgical risk factor would decrease if the surgical client maintained strict blood glycemic control?
Observe for muscle twitching and numbness or tingling of the lips, fingers, and toes. Muscle twitching and numbness or tingling of the lips, fingers, and toes are signs of hyperirritability of the nervous system due to hypocalcemia
A nurse is caring for a client who had a thyroidectomy and is at risk for hypocalcemia. What should the nurse do?
The client is displaying early signs of shock. The early stage of shock manifests with feelings of apprehension and decreased cardiac output. Late signs of shock include worsening cardiac compromise and leads to death if not treated.
A nurse is caring for a client who is three hours post op from open abdominal surgery. During routine assessment, the nurse notes the previously stable client now appears anxious, apprehensive, and has a blood pressure of 90/56. What does the nurse consider is the most likely cause of the client's change in condition?
Wound dehiscence Risk factors for wound dehiscence include advanced age over 65 years, chronic disease such as diabetes, hypertension, obesity, history of radiation or chemotherapy, malnutrition, particularly insufficient protein and vitamin C, and hypoalbuminemia
A nurse is caring for a client with obesity and diabetes after abdominal surgery. What is the client at increased risk for?
beta cells of the pancreas. The beta cells of the pancreas secrete insulin. The alpha cells of the pancreas secrete glucagon, which raises the blood glucose level. The anterior pituitary gland, secretes growth hormone, prolactin, thyroid-stimulating hormone, corticotropin, follicle-stimulating hormone, and luteinizing hormone. The parafollicular cells of the thyroid secrete the hormone calcitonin, which plays a role in calcium metabolism
A nurse is explaining the action of insulin to a client with diabetes mellitus. During client teaching, the nurse reviews the process of insulin secretion in the body. The nurse is correct when she states that insulin is secreted from the
100 units of regular insulin in normal saline solution Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls
A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?
100 units of regular insulin in normal saline solution Continuous insulin infusions use only short-acting regular insulin. Insulin is added to normal saline solution and administered until the client's blood glucose level falls. Further along in the therapy, a dextrose solution is administered to prevent hypoglycemia
A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy?
The short-acting insulin is withdrawn before the intermediate-acting insulin. When combining two types of insulin in the same syringe, the short-acting regular insulin is withdrawn into the syringe first and the intermediate-acting insulin is added next. This practice is referred to as "CLEAR TO CLOUDY" or "R.N".
A nurse is preparing to administer two types of insulin to a client with diabetes mellitus. What is the correct procedure for preparing this medication?
"If you smoke cigarettes, quitting will greatly reduce your risk of bladder cancer."
A nurse is presenting at a community health promotion fair that is focused on disease prevention and screening. A middle-aged participant has brought up an article that she recently read about bladder cancer and has asked the nurse about prevention measures. How should the nurse respond to this woman's inquiry?
Change the needle every 3 days.
A nurse is teaching a client about insulin infusion pump use. What intervention should the nurse include to prevent infection at the injection site?
Glucagon During a hypoglycemic reaction, a layperson may administer glucagon, an antihypoglycemic agent, to raise the blood glucose level quickly in a client who can't ingest an oral carbohydrate
A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?
"Insulin permits entry of glucose into the cells of the body." "Insulin promotes synthesis of proteins in various body tissues." "Insulin promotes the storage of fat in adipose tissue."
A nurse prepares teaching for a client with newly-diagnosed diabetes. Which statements about the role of insulin will the nurse include in the teaching? Select all that apply
Diabetes mellitus Increased urinary glucose levels create an infection-prone environment in the urinary tract.
A nurse who works in a clinic sees many patients with a variety of medical conditions. The nurse understands that a risk factor for UTIs is which of the following?
Fluid volume deficit related to increased urine output The hallmark of diabetes insipidus, and the primary focus of interventions, is the copious urine output that accompanies the condition
A patient has been admitted to an acute medical unit with a diagnosis of diabetes insipidus with a neurogenic etiology. When planning this patient's care, what diagnosis should be the nurse's most likely priority?
Cipro Ciprofloxacin (Cipro) is a fluoroquinolone used to treat UTIs. Co-trimoxazole (Bactrim, Septra) is a trimethoprim-sulfamethoxazole combination medication. Nitrofurantoin (Macrodantin, Furadantin) is an anti-infective urinary tract medication.
A patient has been diagnosed with a UTI and is prescribed an antibiotic. What first-line fluoroquinolone antibacterial agent for UTIs has been found to be significantly effective?
Call the health care provider.
A post op client reports severe abdominal pain. The nurse cannot auscultate bowel sounds and notes the client's abdomen is rigid. What is the nurse's priority action?
Reviewing the patient's diet history to identify eating habits and lifestyle and cultural eating patterns The first step in preparing a meal plan is a thorough review of the patient's diet history to identify eating habits and lifestyle and cultural eating patterns.
A patient has been newly diagnosed with type 2 diabetes, and the nurse is assisting with the development of a meal plan. What step should be taken into consideration prior to making the meal plan?
Monitor urine output hourly and report output less than 30 mL/hr. If urinary drainage stops or decreases to less than 30 mL/hour, or if the client complains of back pain, the nurse needs to notify the physician immediately
A patient has had surgery to create an ileal conduit for urinary diversion. What is a priority intervention by the nurse in the postoperative phase of care?
Ketosis-prone Little or no endogenous insulin Younger than 30 years of age Type I diabetes mellitus is associated with the following characteristics: onset any age, but usually young (<30 y); usually thin at diagnosis, recent weight loss; etiology includes genetic, immunologic, and environmental factors (e.g., virus); often have islet cell antibodies; often have antibodies to insulin even before insulin treatment; little or no endogenous insulin; need exogenous insulin to preserve life; and ketosis prone when insulin absent
A patient is diagnosed with type 1 diabetes. What clinical characteristics does the nurse expect to see in this patient? Select all that apply
A decrease in urine output Desmopressin (DDAVP), a synthetic vasopressin without the vascular effects of natural ADH, is particularly valuable because it has a longer duration of action and fewer adverse effects than other preparations previously used to treat the disease. DDAVP and lypressin (Diapid) reduce urine output to 2 to 3 L/24 hours
A patient is ordered desmopressin (DDAVP) for the treatment of diabetes insipidus. What therapeutic response does the nurse anticipate the patient will experience?
The patient is experiencing a cerebral fluid shift. Dialysis disequilibrium results from cerebral fluid shifts. Signs and symptoms include headache, nausea and vomiting, restlessness, decreased level of consciousness, and seizures. It is rare and more likely to occur in AKI or when BUN levels are very high (exceeding 150 mg/dL).
A patient is placed on hemodialysis for the first time. The patient complains of a headache with nausea and begins to vomit, and the nurse observes a decreased level of consciousness. What does the nurse determine has happened?
When the medication is discontinued or changed, the incontinence will resolve.
A patient taking an alpha-adrenergic medication for the treatment of hypertension is having a problem with incontinence. What does the nurse tell the patient?
The moon face and acne will resolve when the medication is tapered off.
A patient taking corticosteroids for exacerbation of Crohn's disease comes to the clinic and informs the nurse that he wants to stop taking them because of the increase in acne and moon face. What can the nurse educate the patient regarding these symptoms?
Muscle twitching Loss of parathyroid function can result in complaints of paresthesias (perioral, extremities) and fasciculations (muscle twitching), therefore the nurse asks the patient about neuromuscular manifestations.
A patient who has had a total parathyroidectomy has returned to the unit from PACU. The nurse caring for the patient knows to assess for what complication following this surgery?
Myxedema coma Myxedema coma is a rare life-threatening condition. It is the decompensated state of severe hypothyroidism in which the patient is hypothermic and unconscious (Ross, 2012a). This condition may develop with undiagnosed hypothyroidism and may be precipitated by infection or other systemic disease or by use of sedatives or opioid analgesic agents. Patients may also experience myxedema coma if they forget to take their thyroid replacement medication.
A patient with a history of hypothyroidism is admitted to the intensive care unit unconscious and with a temperature of 95.2ºF. A family member informs the nurse that the patient has not taken thyroid medication in over 2 months. What does the nurse suspect that these findings indicate?
Anemia
A patient with chronic kidney failure experiences decreased levels of erythropoietin. What serious complication related to those levels should the nurse assess for when caring for this client?
Goiter A goiter can result from inadequate dietary intake of iodine associated with changes in foods or malnutrition. It's caused by insufficient thyroid gland production and depletion of glandular iodine. Signs and symptoms of goiter include an enlarged thyroid gland, dizziness when raising the arms above the head, dysphagia, and respiratory distress.
A woman with a progressively enlarging neck comes into the clinic. She mentions that she has been in a foreign country for the previous 3 months and that she didn't eat much while she was there because she didn't like the food. She also mentions that she becomes dizzy when lifting her arms to do normal household chores or when dressing. What endocrine condition should the nurse expect the health care provider to diagnose?
pituitary disorder Pituitary disorders usually result from excessive or deficient production and secretion of a specific hormone. Dwarfism occurs when secretion of growth hormone is insufficient during childhood.
A young client has a significant height deficit and is to be evaluated for diagnostic purposes. What could be the cause of this client's disorder?
"I might need insulin later on but probably not as much or as often." Transplanted islet cells tend to lose their ability to function over time, and approximately 70% of recipients resume insulin administration in 2 years. However, the amount of insulin and the frequency of its administration are reduced because of improved control of blood glucose levels.
After teaching a client with type 1 diabetes who is scheduled to undergo an islet cell transplant, which client statement indicates successful teaching?
"It is appropriate to warm the dialysate in a microwave." The dialysate should be warmed in a commercial warmer and never in a microwave oven. Strict aseptic technique is essential. The infusion clamp is opened during the infusion and clamped after the infusion. When the dwell time is done, the drain clamp is opened and the fluid is allowed to drain by gravity into the drainage bag
After teaching a group of students about how to perform peritoneal dialysis, which statement would indicate to the instructor that the students need additional teaching?
Decreased pelvic muscle tone due to multiple pregnancies Stress incontinence is due to decreased pelvic muscle tone, which is associated with multiple pregnancies, obstetric injuries, obesity, menopause, or pelvic disease.
After teaching a group of students about the types of urinary incontinence and possible causes, the instructor determines that the students have understood the material when they identify which of the following as a cause of stress incontinence?
It's an abnormal finding that requires further assessment. The drop in urine output to less than 30 ml/hour is abnormal and requires further assessment. The reduction in urine output may be caused by an obstruction in the urinary catheter tubing or deficient fluid volume from blood loss.
After undergoing retropubic prostatectomy, a client returns to his room. The client is on nothing-by-mouth status and has an IV infusing in his right forearm at a rate of 100 ml/hour. The client also has an indwelling urinary catheter that's draining light pink urine. While assessing the client, the nurse notes that his urine output is red and has dropped to 15 ml and 10 ml for the last 2 consecutive hours. How can the nurse best explain this drop in urine output?
10 to 15 g of a simple carbohydrate To reverse hypoglycemia, the American Diabetes Association recommends ingesting 10 to 15 g of a simple carbohydrate, such as three to five pieces of hard candy, two to three packets of sugar (4 to 6 tsp), or 4 oz of fruit juice. Then the client should check his blood glucose after 15 minutes. If necessary, this treatment may be repeated in 15 minutes.
An agitated, confused client arrives in the emergency department. The client's history includes type 1 diabetes, hypertension, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dl, and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting:
Application of an ostomy pouch An ileal conduit involves care of a urinary stoma, much like that of a fecal stoma, including the application of an ostomy pouch, skin protection, and stoma care
An ileal conduit is created for a client after a radical cystectomy. Which of the following would the nurse expect to include in the client's plan of care?
"This type of dialysis will provide more independence." Once a treatment choice has been selected by the client, the nurse should support the client in that decision. Continuous cyclic peritoneal dialysis will provide more independence for this client and supports the client's decision for treatment mode. The risk of peritonitis is greater, and symptoms should be discussed as part of the management of the disorder. Peritoneal dialysis is an effective method of dialysis for many clients.
An investment banker with chronic renal failure informs the nurse of the choice for continuous cyclic peritoneal dialysis. Which is the best response by the nurse?
Bladder retraining
Behavioral interventions for urinary incontinence can be coordinated by a nurse. A comprehensive program that incorporates timed voiding and urinary urge inhibition is referred to as what?
Sympathetic Beta-adrenergic blocking agents are important in controlling the sympathetic nervous system effects of hyperthyroidism. For example, propranolol is used to control nervousness, tachycardia, tremor, anxiety, and heat intolerance.
Beta-blockers are used in the treatment of hyperthyroidism to counteract which of the following effects?
Observe stool color. The nurse should observe the color of each stool and test the stool for occult blood.
Which assessment would a nurse perform on a client with Cushing's syndrome who is at high risk of developing a peptic ulcer?
phosphorus PTH increases the serum calcium level and decreases the serum phosphate level. PTH doesn't affect sodium, potassium, or magnesium regulation.
During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and:
malignant hyperthermia Malignant hyperthermia is an inherited disorder that occurs when body temperature, muscle metabolism, and heat production increase rapidly, progressively, and uncontrollably in response to stress and some anesthetic agents. If the client's temperature begins to rise rapidly, anesthesia is discontinued, and the OR team implements measures to correct physiologic problems, such as fever or dysrhythmias. Signs of infection would not present during the procedure.
During a procedure, a client's temperature begins to rise rapidly. This is likely the result of which complication?
Detecting evidence of hormone hypersecretion The evaluation of body structures helps the nurse detect evidence of hypersecretion or hyposecretion of hormones. This helps in the assessment of findings that are unique to specific endocrine glands
During physical examination of a client with a suspected endocrine disorder, the nurse assesses the body structures. The nurse gathers this data based on the understanding that it is an important aid in which of the following?
dantrolene sodium (Dantrium) The client is exhibiting clinical manifestations of malignant hyperthermia. Dantrolene sodium, a skeletal muscle relaxant, is administered
During the surgical procedure, the client exhibits tachycardia, generalized muscle rigidity, and a temperature of 40 C. The nurse should prepare to administer:
SpO2 at 90% with fine crackles in the lung bases The Risk for Ineffective Breathing Pattern is often a challenge in caring for clients postnephrectomy due to location of incision. Nursing interventions should be directed to improve and maintain SpO2 levels at 90% or greater and keep lungs clear of adventitious sound
Following a nephrectomy, which assessment finding is most important in determining nursing care for the client?
Maintaining room temperature in the low-normal range Graves' disease causes signs and symptoms of hypermetabolism, such as heat intolerance, diaphoresis, excessive thirst and appetite, and weight loss. To reduce heat intolerance and diaphoresis, the nurse should keep the client's room temperature in the low-normal range.
For a client with Graves' disease, which nursing intervention promotes comfort?
3 months
Glycosylated hemoglobin reflects blood glucose concentrations over which period of time?
Stimulation of calcium reabsorption and phosphate excretion PTH stimulates the kidneys to reabsorb calcium and excrete phosphate and converts vitamin D to its active form, 1,25-dihydroxyvitamin D.
Parathyroid hormone (PTH) has which effects on the kidney?
Increase their fluid intake so that they can excrete up to 4 liters every day.
Patients with urolithiasis need to be encouraged to:
Diuresis period of AKI
Period of AKI marked by a gradual increase in urine output; hypovolemia, dehydration, hypotension
oliguria period of AKI
Period of AKI with: Increase BUN+creatinine, low urine output Metabolic Acidosis Hyperkalemia, hyponatremia Fatigue, malaise
Cola-colored urine Clinical manifestations of acute glomerulonephritis include cola-colored urine, hematuria, edema, azotemia, and proteinuria
The client is admitted to the hospital with a diagnosis of acute glomerulonephritis. Which clinical manifestation would the nurse expect to find?
Increases ability for glucose to get into the cell and lowers blood sugar
The client who is managing diabetes through diet and insulin control asks the nurse why exercise is important. Which is the best response by the nurse to support adding exercise to the daily routine?
Diminished erythropoietin production Erythropoietin is a hormone produced in the kidneys, and this production is inadequate in chronic renal failure, which results in anemia.
The client with chronic renal failure is exhibiting signs of anemia. Which is the best nursing rationale for this symptom?
Autoimmune thyroiditis The most common cause of hypothyroidism is autoimmune thyroiditis (Hashimoto's disease), in which the immune system attacks the thyroid gland.
The most common cause of hypothyroidism is which of the following?
Oliguria phase The oliguria period is accompanied by an increase in the serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, and the intracellular cations [potassium and magnesium])
The nurse cares for a client with acute kidney injury (AKI). The client is experiencing an increase in the serum concentration of urea and creatinine. The nurse determines the client is experiencing which phase of AKI?
pH 7.20, PaCO2 36, HCO3 14- Metabolic acidosis occurs in end-stage kidney disease (ESKD) because the kidneys are unable to excrete increased loads of acid.
The nurse cares for a client with end-stage kidney disease (ESKD). Which acid-base imbalance is associated with this disorder?
Keep the dialysis supplies in a clean area, away from children and pets It is important to keep the dialysis supplies in a clean area, away from children and pets, because the supplies may be dangerous for them. A mask is generally worn only while performing exchanges, especially when a client has an upper respiratory infection. The catheter insertion site should be cleaned DAILY with an ANTISEPTIC such as povidone-iodine, not with soap. In addition, the catheter should be stabilized to the abdomen ABOVE the BELT LINE, not below the belt line, to avoid constant rubbing
The nurse helps a client to correctly perform peritoneal dialysis at home. The nurse must educate the client about the procedure. Which educational information should the nurse provide to the client?
Regular Short-acting insulins are called regular insulin (marked R on the bottle). Regular insulin is a clear solution and is usually administered 20 to 30 minutes before a meal, either alone or in combination with a longer-acting insulin. Regular insulin is the only insulin approved for IV use.
The nurse is administering an insulin drip to a patient in ketoacidosis. What insulin does the nurse know is the only one that can be used intravenously?
10 to 15 minutes The onset of action of rapid-acting lispro insulin is within 10 to 15 minutes. It is used to rapidly reduce the glucose level
The nurse is administering lispro insulin. Based on the onset of action, how long before breakfast should the nurse administer the injection?
The stoma is dusky red. A dusky red color indicates the blood supply of the stoma is compromised and suggests superficial necrosis of the stoma
The nurse is assessing the client's ileal conduit stoma in the clinic. Which assessment finding would be of greatest concern to the nurse?
Away from skin folds The nurse plans to have the stoma located away from skin folds and creases, bony prominences, the belt line, and the umbilicus. The stoma should be located in an area where the client can see and reach it.
The nurse is assisting in the preoperative planning for stoma placement in a client scheduled for urinary diversion surgery. Where should the nurse plan for the stoma to be located?
Hypocalcemia Hypoparathyroidism results in hypocalcemia, which triggers a series of physiologic responses, including the choices presented
The nurse is aware that the clinical symptoms of a patient with hypoparathyroidism are the result of the initial physiologic response of:
Ileal conduit When the physician is discussing a stoma, the nurse recognizes that the client will have an ileal conduit which is a cetaceous urinary diversion. Both the Kock Pouch and Indiana Pouch are continent urinary diversions. The ureterosigmoidostomy connects with the rectum for urinary drainage
The nurse is caring for a client diagnosed with bladder cancer and requiring a cystectomy. The nurse overhears the physician instructing the client on the presence of a stoma with temporary pouch. In gathering information for the client, which urinary diversion would the nurse select?
"My urine will be eliminated through a stoma." An ileal conduit is a non-continent urinary diversion whereby the ureters drain into an isolated section of ileum. A stoma is created at one end of the ileum, exiting through the abdominal wall.
The nurse is caring for a client who is scheduled for the creation of an ileal conduit. Which statement by the client provides evidence that client teaching was effective?
New diagnosis of urosepsis The most concerning risk factor is urosepsis, which is a serious systemic infection from microorganisms in the urinary tract invading the bloodstream.
The nurse is caring for a client with a cystoscopy tube draining urine from the bladder. When reviewing the client's history prior to administering care, which is of most concern?
Hypovolemic shock caused by hemorrhage
The nurse is caring for a patient after kidney surgery. What major danger should the nurse closely monitor for?
Hyperkalemia The administration of glucose and regular insulin, with sodium bicarbonate if necessary, can temporarily prevent cardiac arrest by moving potassium into the cells and temporarily reducing serum potassium levels.
The nurse is caring for a patient in acute renal failure. The nurse should expect hypertonic glucose, insulin infusions, and sodium bicarbonate to be used to treat:
Temperature of 102ºF Thyroid storm is characterized by the following: 1) high fever (hyperpyrexia), >38.5°C (>101.3°F); 2) extreme tachycardia (>130 bpm); 3) exaggerated symptoms of hyperthyroidism with disturbances of a major system—for example, gastrointestinal (weight loss, diarrhea, abdominal pain) or cardiovascular (edema, chest pain, dyspnea, palpitations); and 4) altered neurologic or mental state, which frequently appears as delirium psychosis, somnolence, or coma.
The nurse is caring for a patient with hyperthyroidism who suddenly develops symptoms related to thyroid storm. What symptoms does the nurse recognize that are indicative of this emergency?
Peritonitis
The nurse is caring for a postoperative client who has a Kock pouch. Nursing assessment findings reveal abdominal pain, absence of bowel sounds, fever, tachycardia, and tachypnea. The nurse suspects which of the following?
Cardiovascular system Depolarizing muscle relaxants can cause cardiac dysrhythmias.
The nurse is completing a postoperative assessment for a patient who has received a depolarizing neuromuscular blocking agent. The nursing assessment includes careful monitoring of which body system?
It carries glucose into body cells.
The nurse is describing the action of insulin in the body to a client newly diagnosed with type 1 diabetes. Which of the following would the nurse explain as being the primary action?
Citrus fruits Foods and fluids containing potassium or phosphorus (e.g., bananas, citrus fruits and juices, coffee) are restricted.
The nurse is educating a client who is required to restrict potassium intake. What foods would the nurse suggest the client eliminate that are rich in potassium?
Take the antibiotic for 3 days as prescribed.
The nurse is educating a female patient with a UTI on the pharmacologic regimen for treatment. What is important for the nurse to instruct the patient to do?
Anticholinergic Pharmacologic agents that can improve bladder retention, emptying, and control include anticholinergic drugs. In this classification are medications such as Detrol, Ditropan, and Urecholine.
The nurse is employed in a urologist's office. Which classification of medication is anticipated for clients having difficulty with urinary incontinence?
Insulin resistance or insufficient insulin production Type 2 diabetes is characterized by insulin resistance or insufficient insulin production. It is more common in aging adults and now accounts for 20% of all newly diagnosed cases. Type 1 diabetes is more likely in childhood and adolescence; although, it can occur at any age. It accounts for approximately 5% to 10% of all diagnosed cases of diabetes. Prediabetes can lead to type 2 diabetes.
The nurse is preparing a presentation for a group of adults at a local community center about diabetes. Which of the following would the nurse include as associated with type 2 diabetes?
NPH Intermediate-acting insulins are called NPH insulin (neutral protamine Hagedorn) or Lente insulin. Lispro (Humalog) is rapid acting, Iletin II is short acting, and glargine (Lantus) is very long acting.
The nurse is preparing to administer intermediate-acting insulin to a patient with diabetes. Which insulin will the nurse administer?
Perform hand hygiene prior to patient care. Assist the patients with frequent toileting. Provide careful perineal care
The nurse is providing an education program for the nursing assistants in a long-term care facility in order to decrease the number of UTIs in the female population. What interventions should the nurse introduce in the program? Select all that apply.
A rise in serum calcium stimulates the release of calcitonin from the thyroid gland.
The nurse is reviewing a client's laboratory studies and determines that the client has an elevated calcium level. What does the nurse know will occur as a result of the rise in the serum calcium level?
potassium 6.2 mEq/L Hyperkalemia places the client at risk for surgical complications
The nurse is reviewing the pre-admission laboratory findings of the client scheduled for surgery. Which laboratory value would be of greatest concern to the nurse?
Therapeutic drug levels can be maintained more evenly with patient-controlled analgesia. Advantages of patient-controlled analgesia include participation of the client in care, elimination of delayed administration of analgesics, and maintenance of therapeutic drug levels. The client must have the cognitive and physical abilities to self-dose.
The nurse is teaching the client about patient-controlled analgesia. Which of the following would be appropriate for the nurse to include in the teaching plan?
Hold the medications until after dialysis. Antihypertensive therapy, often part of the regimen of clients on dialysis, is one example when communication, education, and evaluation can make a difference in client outcomes. The client must know when—and when not—to take the medication. For example, if an antihypertensive agent is taken on a dialysis day, hypotension may occur during dialysis, causing dangerously low blood pressure. Many medications that are taken once daily can be held until after dialysis treatment
The nurse passes out medications while a client prepares for hemodialysis. The client is ordered to receive numerous medications including antihypertensives. What is the best action for the nurse to take?
Change the wafer and pouch. Whenever a leaking pouching system is noted, the nurse should change the wafer and pouch. Attempting to secure or patch the leak with tape and/or barrier paste can trap urine under the barrier or faceplate, which will compromise peristomal skin integrity. Emptying the pouch will not rectify the leaking.
The nurse working with a client after an ileal conduit notices that the pouching system is leaking small amounts of urine. What is the appropriate nursing intervention?
Blood urea nitrogen (BUN)-to-creatinine ratio (BUN:Cr) >20. The normal BUN:Cr ratio is less than 15. Prerenal azotemia is caused by hypoperfusion of the kidneys due to a nonrenal cause. Over time, higher than normal blood levels of urea or other nitrogen-containing compounds will develop
The presence of prerenal azotemia is a probable indicator for hospitalization for CAP. Which of the following is an initial laboratory result that would alert a nurse to this condition?
by occluding the blood flow to the arm for 3 minutes with the use of a blood pressure cuff
Trousseau sign is elicited
Sodium polystyrene sulfonate Exhanges Na for K ions
What is used to decrease potassium level seen in acute renal failure?
Vasopressin Because diabetes insipidus results from decreased antidiuretic hormone (vasopressin) production, the nurse should expect to administer synthetic vasopressin for hormone replacement therapy
When caring for a client with diabetes insipidus, the nurse expects to administer:
High blood sugar decreases blood circulation to nerves. Diabetic neuropathy results from poor glucose control and decreased blood circulation to nerve tissues. The lack of sensitivity increases the potential for soft tissue injury without awareness.
When the nurse inspects the feet of a diabetic, a tack is found sticking in the sole of one foot. The client denies feeling anything unusual in the foot. Which is the best rationale for this finding?
Angina Angina or dysrhythmias can occur when thyroid replacement is initiated because thyroid hormones enhance the cardiovascular effects of catecholamines
When thyroid hormone is administered for prolonged hypothyroidism for a patient, what should the nurse monitor for?
Do not mix with other insulins. Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation.
Which information should be included in the teaching plan for a client receiving glargine, a "peakless" basal insulin?
Have regular follow-up care The nurse should instruct the client with Graves' disease to have regular follow-up care because most cases of Graves' disease eventually result in hypothyroidism. Annual thyroid-stimulating hormone tests and the client's ability to recognize signs and symptoms of thyroid dysfunction will help detect thyroid abnormalities early.
Which instruction should be included in the discharge teaching plan for a client after thyroidectomy for Graves' disease?
Maintaining a patent airway Because respirations are depressed in myxedema coma, maintaining a patent airway is the most critical nursing intervention. Ventilatory support is usually needed. Although myxedema coma is associated with severe hypothermia, a warming blanket shouldn't be used because it may cause vasodilation and shock. Gradual warming with blankets is appropriate.
Which intervention is the most critical for a client with myxedema coma?
Encourage midday snack. Because NPH is an intermediate-acting insulin that peaks in approximately 4 to 12 hours, a midday snack should be included in daily calorie intake to avoid hypoglycemia.
Which is the primary dietary consideration for a client receiving insulin isophane suspension (NPH) at breakfast?
T4, 2 µg/dl; T3, 35 ng/dl; TSH 45 mIU/ml Normal thyroid function tests are as follows: T4, 5 to 12 µg/dl; T3, 65 to 195 ng/dl; TSH 0.3 to 5.4 mIU/ml. With Hashimoto's thyroiditis, T4 and T3 levels are typically subnormal and TSH is elevated.
Which laboratory test results should a nurse expect to find in a client diagnosed with Hashimoto's thyroiditis?
Deficient knowledge: management of urinary diversion Disturbed body image Risk for impaired skin integrity
Which nursing diagnosis is appropriate for the client with a new ileal conduit? Select all that apply.
Change in cognitive functioning
Which objective symptom of a UTI is most common in older adults, especially those with dementia?
Discarding an object that comes in contact with the 1-inch border The 1-inch border of a sterile field is considered unsterile.
Which of the following actions by the nurse is appropriate?
Sodium iodide Potassium iodide Dexamethasone Saturated solution of potassium iodide (SSKI)
Which of the following agents suppress release of thyroid hormones? Select all that apply.
Glomerulonephritis Intrarenal causes of renal failure include prolonged renal ischemia, nephrotoxic agents, and infectious processes such as acute glomerulonephritis. INTRARENAL = PROBLEM AT KIDNEYS
Which of the following causes should the nurse suspect in a client diagnosed with intrarenal failure?
The client has eaten and has not taken or received insulin. If the client has eaten and has not taken or received insulin, DKA is more likely to develop.
Which of the following factors would a nurse identify as a most likely cause of diabetic ketoacidosis (DKA) in a client with diabetes?
Adrenocorticotropic hormone (ACTH) ACTH controls the secretion of adrenal androgens. When secreted in normal amounts, the adrenal androgens appear to have little effect, but when secreted in excess, as in certain inborn enzyme deficiencies, masculinization may result.
Which of the following hormones controls secretion of adrenal androgens?
Excessive intake of vitamin D Potential causes of calcium renal stones include excessive intake of vitamin D, hypercalcemia, hyperparathyroidism, excessive intake of milk and alkali, and renal tubular acidosis.
Which of the following is a cause of a calcium renal stone?
Strain the urine carefully for stone fragments. The nurse should strain all urine following lithotripsy. Stone fragments are sent to the laboratory for chemical analysis
Which of the following nursing actions is most important in caring for the client following lithotripsy?
Peripheral neuropathy Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with or without a pericardial friction rub. The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure
Which of the following occurs late in chronic glomerulonephritis?
Peripheral neuropathy Peripheral neuropathy with diminished deep tendon reflexes and neurosensory changes occur late in the disease. The patient becomes confused and demonstrates a limited attention span. An additional late finding includes evidence of pericarditis with or without a pericardial friction rub. The first indication of disease may be a sudden, severe nosebleed, a stroke, or a seizure.
Which of the following occurs late in chronic glomerulonephritis?
Septic shock Prerenal causes of acute renal failure include hypovolemic shock, cardiogenic shock secondary to congestive heart failure, septic shock, anaphylaxis, dehydration, renal artery thrombosis or stenosis, cardiac arrest, and lethal dysrhythmias
Which of the following would a nurse classify as a prerenal cause of acute renal failure?
"I'll wear cotton socks with well-fitting shoes." The client demonstrates understanding of proper foot care if he states that he'll wear cotton socks with well-fitting shoes because cotton socks wick moisture away from the skin, helping to prevent fungal infections, and well-fitting shoes help avoid pressure areas.
Which statement indicates that a client with diabetes mellitus understands proper foot care?
A glucose challenge test should be performed between 24 and 28 weeks. A glucose challenge test should be performed between 24 and 28 weeks in women at average risk. It occurs in less than 10% of all pregnancies. Onset usually occurs in the second or third trimester. There is an above-normal risk for perinatal complications.
Which statement is true regarding gestational diabetes?
Use the hands to support the head when rising from a sitting position. After a thyroidectomy, the client should use the hands to support the head while rising from a sitting position. This type of support helps avoid strain to the neck muscles and surgical incision
Which suggestion would the nurse include for a client who has had a thyroidectomy to reduce tension on the suture line?
Positive Chvostek's sign
While assessing a client with hypoparathyroidism, the nurse taps the client's facial nerve and observes twitching of the mouth and tightening of the jaw. The nurse would document this finding as which of the following?
