MedSurg Final
A patient states that she rates her pain as a "5" on a 0-to-10 scale post-mastectomy. The provider has ordered morphine 4 mg for moderate pain every 4 hours. The morphine is supplied in a solution of 8 mg/mL. How many mL will the nurse administer? ____ mL
0.5 mL 4mg/x = 8mg/1mL 8x=4 x=0.5 mL
The client with DM is to receive insulin IV at 1.5 units per hour. The insulin bag contains 100 units of insulin in 100ml of NS. The nurse should set the infusion pump to deliver how many milliliters per hour? _________________ml/hour (Record your answer rounded to the nearest tenth).
1.5 mL/hr We know the units per hour and the mL per unit. So multiply mL/units by units/hr and the units cancels out leaving what we need: mL/hr.
Post transurethral resection of the prostate, a patient has a three-way catheter with a continuous bladder irrigation. Over the last 12 hours, there has been 1400 mL of irrigation solution infused and 2000 mL measured in output from the drainage bag. What is the recording of the urinary output for the 12-hour period? (Record your answer using a whole number.) ____ mL
600 mL 2000 mL from the drainage bag (including both the irrigation fluid and urine) minus the 1400 mL of irrigation fluid equals 600 mL of urine: 2000 mL - 1400 mL = 600 mL
A client asks why a 24-hour urine collection is necessary to measure excreted hormones instead of a random voided specimen. Which response by the nurse is most accurate? A. "We are testing for a hormone secreted on a circadian rhythm." B. "The hormone is so dilute in urine, we need a large volume." C. "We want to see when the hormone is secreted in both large and small amounts." D. "You'd have to be here at a specific time of the day for a random urinalysis."
A
A client who is receiving chemotherapy asks the nurse, "Why is so much of my hair falling out each day?" Which response by the nurse best explains the reason for alopecia? A. "Chemotherapy affects the cells of the body that grow rapidly, both normal and malignant." B. "Alopecia is a common side effect you will experience during long-term steroid therapy." C. "Your hair will grow back completely after your course of chemotherapy is completed." D. "The chemotherapy causes permanent alterations in your hair follicles that lead to hair loss."
A
A nurse assesses a client with diabetes mellitus and notes the client only responds to a sternal rub by moaning, has capillary blood glucose of 33 g/dL, and has an intravenous line that is infiltrated with 0.45% normal saline. Which action should the nurse take first? A. Administer 1 mg of intramuscular glucagon. B. Encourage the client to drink orange juice. C. Insert a new intravenous access line. D. Administer 25 mL dextrose 50% (D50) IV push.
A
A nurse in the oncology clinic is providing preoperative education to a patient just diagnosed with cancer. The patient has been scheduled for surgery in 3 days. What action by the nurse is best? A. Call the patient at home the next day to review teaching. B. Give the patient information about a cancer support group. C. Provide all the preoperative instructions in writing. D. Reassure the patient that surgery will be over soon.
A
A nurse reads on a hospitalized patient's chart that the patient is receiving teletherapy. What action by the nurse is best? A. Coordinate continuation of the therapy. B. Place the patient on radiation precautions. C. No action by the nurse is needed at this time. D. Restrict visitors to only adults over age 18.
A
A nurse working with patients who experience alopecia knows that which is the best method of helping patients manage the psychosocial impact of this problem? A. Assisting the patient to pre-plan for this event B. Reassuring the patient that alopecia is temporary C. Teaching the patient ways to protect the scalp D. Telling the patient that there are worse side effects
A
A nurse works on an oncology unit and delegates personal hygiene to an unlicensed assistive personnel (UAP). What action by the UAP requires intervention from the nurse? A. Allowing a very tired patient to skip oral hygiene and sleep B. Assisting patients with washing the perianal area every 12 hours C. Helping the patient use a soft-bristled toothbrush for oral care D. Reminding the patient to rinse the mouth with water or saline
A
A patient asks the nurse if eating only preservative- and dye-free foods will decrease cancer risk. What response by the nurse is best? A. "Maybe; preservatives, dyes, and preparation methods may be risk factors." B. "No; research studies have never shown those things to cause cancer." C. "There are other things you can do that will more effectively lower your risk." D. "Yes; preservatives and dyes are well known to be carcinogens."
A
A patient hospitalized for chemotherapy has a hemoglobin of 6.1 mg/dL. What medication should the nurse prepare to administer? A. Epoetin alfa (Epogen) B. Filgrastim (Neupogen) C. Mesna (Mesnex) D. Oprelvekin (Neumega)
A
A patient is discharged to home after a modified radical mastectomy with two drainage tubes. Which statement by the patient would indicate that further teaching is needed? A. "I am glad that these tubes will fall out at home when I finally shower." B. "I should measure the drainage each day to make sure it is less than an ounce." C. "I should be careful how I lie in bed so that I will not kink the tubing." D. "If there is a foul odor from the drainage, I should contact my doctor."
A
A patient is lying in bed after a mastectomy. How does the nurse position the patient? A. Head of the bed up at least 30 degrees with the affected arm elevated on a pillow. B. Supine with affected arm positioned straight by the side C. Any position that is most comfortable for the patient D. Side-lying position with the unaffected side down towards the mattress
A
A patient is receiving chemotherapy through a peripheral IV line. What action by the nurse is most important? A. Assessing the IV site every hour B. Educating the patient on side effects C. Monitoring the patient for nausea D. Providing warm packs for comfort
A
A patient is receiving interleukins along with chemotherapy. What assessment by the nurse takes priority? A. Blood pressure B. Lung assessment C. Oral mucous membranes D. Skin integrity
A
A patient newly diagnosed with Type I DM is being seen by the home health nurse. The doctor's orders include: 1200 calorie ADA diet, 15 units NPH insulin before breakfast, and check blood sugar qid. When the nurse visits the patient at 5 pm, the nurse observes the man performing blood sugar analysis. The result is 50 mg/dL. The nurse would expect the patient to be a. confused with cold, clammy skin and pulse of 110 b. lethargic with hot dry skin and rapid deep respirations c. alert and cooperative with BP of 130/80 and respirations of 12 d. short of breath, with distended neck veins and bounding pulse of 96
A
A patient with a history of prostate cancer is in the clinic and reports new onset of severe low back pain. What action by the nurse is most important? A. Assess the patient's gait and balance. B. Ask the patient about the ease of urine flow. C. Document the report completely. D. Inquire about the patient's job risks.
A
A woman diagnosed with breast cancer had the following lab tests performed at an office visit: Alkaline phosphatase: 125 U/L Total calcium: 12 mg/dL Hematocrit: 39% Hemoglobin: 14 g/dL Which test results indicate to the nurse that some further diagnostics are needed? A. Elevated alkaline phosphatase and calcium suggests bone involvement. B. Only alkaline phosphatase is decreased, suggesting liver metastasis. C. Hematocrit and hemoglobin are decreased, indicating anemia. D. The elevated hematocrit and hemoglobin indicate dehydration.
A
After the home health nurse has taught a patient and family about how to use glargine and regular insulin safely, which action by the patient indicates that the teaching has been successful? a. The patient disposes of the open insulin vials after 4 weeks. b. The patient draws up the regular insulin in the syringe and then draws up the glargine. c. The patient stores extra vials of both types of insulin in the freezer until needed. d. The patient's family prefills the syringes weekly and stores them in the refrigerator.
A
Blood sugar is well controlled when Hemoglobin A1C is: a. Below 6.5-7% b. Between 12%-15% c. Less than 180 mg/dL d. Between 90 and 130 mg/dL
A
Diabetic patients who are prescribed sulfonylurea agents such as Glipiside are at an increased risk for: A. Hypoglycemia B. Hyperglycemia C. DKA D. Hypertension
A
During the first 24 hours after prostatectomy, what is the priority assessment in the nursing care plan? A. Hemorrhage B. Infection C. Hydronephrosis D. Confusion
A
In a 29-year-old female client who is being successfully treated for Cushing's syndrome, the nurse would expect a decline in: A. Serum glucose level B. Hair loss C. Bone mineralization D. Menstral flow
A
In the administration of prednisone, it is vital that the nurse recognize that this drug might mask which symptoms? A. Signs and symptoms of infection B. Signs and symptoms of heart failure C. Hearing loss
A
In the patient with a history of long-term steroid use, sudden cessation of steroid therapy places the patient at risk for: A. Acute adrenal insufficiency B. Hyperparathyroidism C. Hypothyroidism D. Fluid volume overload
A
Mr. A is a 48 yo with a history of Type 2 DM. He is receiving basal bolus insulin therapy while hospitalized for pneumonia. Mr. A's glycemic management orders include: • Lantus 20 units before bedtime 2100. • Bolus (nutritional) insulin 6 units of Lispro • Low dose correctional insulin protocol Before breakfast Mr. A's blood glucose is 115 mg/dL. Mr. A reports to you that he is very nauseated and is not sure if he will eat breakfast. What is your best action? A. Hold Mr. A's scheduled bolus insulin. B. Administer Mr. A's bolus and correctional insulin per orders. C. Administer both doses of Bolus insulin at lunchtime. D. Obtain orders to discontinue Mr. A's bolus insulin.
A
The client has chronic hypercortisolism. Which intervention is the highest priority for the nurse? A. Wash the hands when entering the room. B. Keep the client in protective isolation. C. Observe the client for increased white blood cell counts. D. Assess the daily chest x-ray.
A
The newly diagnosed patient with Addison's disease is started on fludrocortisone (Florinef) a mineralcorticoid replacement drug. The nurse will teach the patient to report any new onset of what symptoms: A. Hypertension and weight gain B. Weight loss and hypotension C. Tetany D. Ringing in the ears
A
The nurse assessing a female client with Cushing's syndrome would expect to note which of the following? A. Hirsutism B. Hypotension C. Hypoglycemia D. Pallor
A
The nurse has completed a community presentation about lung cancer. Which statement from a participant demonstrates an understanding of the information presented? A. "The primary prevention for reducing the risk of lung cancer is to stop smoking and avoid second hand smoke." B. "The overall 5-year survival rate for all patients with lung cancer is 85%." C. "The death rate for lung cancer is less than prostate, breast, and colon cancer combined." D. "Cures are most likely for patients who undergo treatment for stage III disease."
A
The nurse is caring for a patient with a chest tube. What is the correct nursing intervention for this patient? A. The patient is encouraged to cough and do deep-breathing exercises frequently B. Stripping of the chest tube is done routinely to prevent obstruction by blood clots C. Water level in the suction chamber need not be monitored, just the collection chamber D. Drainage containers are positioned upright or on the bed next to the patient
A
The nurse is preparing a teaching plan for a client who is newly diagnosed with Type 1 diabetes mellitus. Which signs and symptoms should the nurse describe when teaching the client about hypoglycemia? A. Sweating, trembling, tachycardia. B. Polyuria, polydipsia, polyphagia. C. Nausea, vomiting, anorexia. D. Fruity breath, tachypnea, chest pain.
A
The nurse is teaching an uncircumcised 65-year-old patient about self-management of a urinary catheter in preparation for discharge to his home. What statement indicates a lack of understanding by the patient? A. "I only have to wash the outside of the catheter once a week." B. "I should take extra time to clean the catheter site by pushing the foreskin back." C. "The drainage bag needs to be changed at least once a week and as needed." D. "I should pour a solution of vinegar and water through the tubing and bag."
A
The nurse understands that a patient with primary adrenal insufficiency will have ACTH (Cosyntropin) stimulation test results that show: A. no increase in cortisol B. an increase in cortisol C. overproduction of ACTH D. underproduction of ACTH
A
The nurse working in a postoperative surgical clinic is assessing a woman who had a left radical mastectomy for breast cancer. Which factor puts this client at greatest risk for developing lymphedema? A. She sustained an insect bite to her arm yesterday B. She lost 20 pounds since the surgery C. Her healthcare provider now prescribes a calcium channel blocker for hypertension. D. Her hobby is playing classical music on the piano.
A
The nurse working with oncology patients understands that which age-related change increases the older patient's susceptibility to infection during chemotherapy? A. Decreased immune function B. Diminished nutritional stores C. Existing cognitive deficits D. Poor physical reserves
A
The patient is postoperative day 1 after an open thoracotomy and has two chest tubes in place on the right. The nurse notes that the trachea is pointing toward the left upper chest. What is the nurse's best action? A. Immediately notify the rapid response team and thoracic surgeon. B. Unplug the suction setting from the chest tube. C. Attempt to reposition the trachea midline. D. No action is needed because the trachea is deviated to the unaffected side.
A
The patient with Cushing's disease will have 24-hr urine test results that show A. Elevated free cortisol/ Ca, K, glucose elevated in urine. B. Decreased free cortisol/ decreased Ca and K+ in the urine C. Elevated free cortisol/ decreased Ca and K+ in the urine D. Decreased free cortisol/ Ca, K, glucose elevated in urine.
A
The patient with Cushing's disease will have serum potassium levels that are: A. less than 3.5 mEq/L B. greater than 5.5 mEq/L C. normal D. greater than 6.0 mEq/L
A
When administering Humalog (Lispro) to a diabetic patient the nurse should ensure that the patient's meal tray arrives no more than __________________minutes prior to administration. A. 15 minutes B. 30 minutes C. 1 hour D. 4 hours
A
Which assessment finding by the nurse during a client's clinical breast examination requires a follow-up? A. Newly retracted nipple B. A thickened area where the skin folds under the breast C. Whitish nipple discharge D. Tender lumpiness noted bilaterally throughout the breast
A
Which drug causes increased risk for peptic ulcers, decreased wound healing, and increased capillary fragility? A. Hydrocortisone (Cortef) B. Antidiuretic hormones C. Antithyroid hormones
A
Which precaution is most important for the nurse to teach a client who is prescribed oral corticosteroids for hormone replacement therapy after adrenalectomy? A. "Do not stop taking this drug without consulting your prescriber." B. "Avoid crowds and people who are ill." C. "Be sure to take this drug with food." D. "Reduce your salt intake."
A
A client has a deficiency of aldosterone. Which assessment finding does the nurse correlate with this condition? A. Increased urine output B. Vasoconstriction C. Blood glucose, 98 mg/dL D. Serum sodium, 144 mEq/L
A A lack of aldosterone leads to fluid loss and hypotension
A nurse is preparing to assess a patient with Cushing's Syndrome. In assessing the patient, a nurse should expect to find: A. Muscle atrophy in lower extremities, weight gain, and bruising. B. A high-pitched voice and male pattern hair distribution. C. Exophthalmos (bulging eyes) and postural hypotension. D. Increased muscle mass, weight loss and low platelet count.
A A patient with Cushing's syndrome will have muscle atrophy in the lower extremities due to protein catabolism; weight gain due to excess mineralocorticoids and easy bruising. Remaining options describe patients with other endocrine disorders or include symptoms inconsistent with Cushing's syndrome (weight loss is not a symptom of Cushing's syndrome).
A client is brought to the emergency department via rescue squad in acute adrenal crisis. Which action by the nurse is the priority? A. Start an IV line immediately B. Administer hydrocortisone sodium succinate (Solu-Cortef). C. Instruct the nursing assistant to check the client's blood glucose. D. Administer 20 units of insulin and 20 mg of dextrose in normal saline.
A A secure and patent IV access will be critical part of treatment management for this person in acute adrenal crisis. Patient will be receive IV meds and fluids.
A patient is diagnosed with metastatic prostate cancer. The patient asks the nurse the purpose of his treatment with the luteinizing hormone-releasing hormone (LH-RH) agonist leuprolide (Lupron) and the bisphosphonate pamidronate (Aredia). Which statement by the nurse is most appropriate? A. "The treatment reduces testosterone and prevents bone fractures." B. "The medications prevent erectile dysfunction and increase libido." C. "There is less gynecomastia and osteoporosis with this drug regimen." D. "These medications both inhibit tumor progression by blocking androgens."
A Teach patients taking LH-RH agonists that side effects include "hot flashes," erectile dysfunction, and decreased libido (desire to have sex). Some men also have gynecomastia (breast tenderness and growth). These drugs can also cause osteoporosis. Bisphosphonates like pamidronate (Aredia) are prescribed to prevent bone fractures. They can also be used to slow the damage caused by bone metastasis.
A patient on interferon therapy is reporting severe skin itching and irritation. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Apply moisturizers to dry skin. B. Apply steroid creams to the skin. C. Bathe the patient using mild soap. D. Help the patient with a hot water bath. E. Teach the patient to avoid sunlight.
A and C
The nurse is caring for the client with type 2 DM. Which instructions should the nurse provide to the client regarding diabetes management during stress or illness? SELECT ALL THAT APPLY A. Notify the health care provider if unable to keep fluids or foods down B. Test fingerstick blood glucose levels and urine ketones every 36 hours and keep a record C. Continue to take oral hyperglycemic medications and/or insulin as prescribed D. Supplement food intake with high carbohydrate fluids, soups, and high sugar juices E. A minor illness, such as the flu, usually does not affect the blood glucose and insulin needs
A and C A. If the client is unable to eat due to nausea and vomiting, dehydration could occur from hyperglycemia and lack of intake. The HCP should be notified. C. an acute or minor illness can evoke counter a regulatory hormones response. Resulting in hyperglycemia, thus the client should continue prescribed medications. Blood glucose and ketones checks should be every 4 hours not every 36 hours.
The student nurse caring for patients who have cancer understands that the general consequences of cancer include which patient problems? (Select all that apply.) A. Increased risk of infection from white blood cell deficits B. Nutritional deficits such as early satiety and cachexia C. Potential for reduced gas exchange D. Various motor and sensory deficits
A, B, C, and D
A nurse is participating in primary prevention efforts directed against cancer. In which activities is this nurse most likely to engage? (Select all that apply.) A. Discussing breast self-examination methods to women B. Instructing people on the use of chemoprevention C. Providing vaccinations against certain cancers D. Screening teenage girls for cervical cancer E. Teaching teens the dangers of tanning booths
A, B, C, and E
A nurse is providing community education on the seven warning signs of cancer. Which signs are included? (Select all that apply.) A. A sore that does not heal B. Changes in menstrual patterns C. Indigestion or trouble swallowing D. Near-daily abdominal pain E. Obvious change in a mole
A, B, C, and E
A patient has mucositis. What actions by the nurse will improve the patient's nutrition? (Select all that apply.) A. Assist with rinsing the mouth with saline frequently. B. Encourage the patient to eat room-temperature foods. C. Give the patient hot liquids to hold in the mouth. D. Provide local anesthetic medications to swish and spit. E. Remind the patient to brush teeth gently after each meal.
A, B, D, and E
A nurse is preparing to administer IV chemotherapy. What supplies does this nurse need? (Select all that apply.) A. "Chemo" gloves B. Facemask C. Isolation gown D. N95 respirator E. Shoe covers
A, B, and C
A patient's family members are concerned that telling the patient about a new finding of cancer will cause extreme emotional distress. They approach the nurse and ask if this can be kept from the patient. What actions by the nurse are most appropriate? (Select all that apply.) A. Ask the family to describe their concerns more fully. t B. Consult with a social worker, chaplain, or ethics committee. t C. Explain the patient's right to know and ask for their assistance. D. Have the unit manager take over the care of this patient and family. E. Tell the family that this secret will not be kept from the patient.
A, B, and C
A woman has been using acupuncture to treat the nausea and vomiting caused by the side effects of chemotherapy for breast cancer. Which conditions would cause the nurse to recommend against further use of acupuncture? (Select all that apply.) A. Lymphedema B. Bleeding tendencies C. Low white blood cell count D. Elevated serum calcium E. High platelet count
A, B, and C
The nurse working with oncology patients understands that interacting factors affect cancer development. Which factors does this include? (Select all that apply.) A. Exposure to carcinogens B. Genetic predisposition C. Immune function D. Normal doubling time E. State of euploidy
A, B, and C
A patient has thrombocytopenia. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Apply the patient's shoes before getting the patient out of bed. B. Assist the patient with ambulation. C. Shave the patient with a safety razor only. D. Use a lift sheet to move the patient up in bed. E. Use the Waterpik on a low setting for oral care.
A, B, and D
The nurse is taking a history of a 68-year-old woman. What assessment findings would indicate a high risk for the development of breast cancer? (Select all that apply.) A. Age greater than 65 years B. Increased breast density C. Osteoporosis D. Multiparity E. Genetic factors
A, B, and E
A patient receiving chemotherapy has a white blood cell count of 1000/mm3. What actions by the nurse are most appropriate? (Select all that apply.) A. Assess all mucous membranes every 4 to 8 hours. B. Do not allow the patient to eat meat or poultry. C. Listen to lung sounds and monitor for cough. D. Monitor the venous access device appearance with vital signs. E. Take and record vital signs every 4 to 8 hours.
A, C, D, and E
After a breast examination, the nurse is documenting assessment findings that indicate possible breast cancer. Which abnormal findings need to be included as part of the patient's electronic medical record? (Select all that apply.) A. Peau d'orange B. Dense breast tissue C. Nipple retraction D. Mobile mass at two o'clock E. Nontender axillary nodes
A, C, and D
The nurse is assessing the client who has type 2 DM. Which findings indicate to the nurse that the client is experiencing HHS? SELECT ALL THAT APPLY A. Serum osmolality 364 mOsm/kg B. Blood glucose level of 160 mg/dL C. Very dry mucous membranes D. Blood pressure of 86/42 E. Urine output of 500ml over the past 8 hours.
A, C, and D (Treat each answer as true false, do not compare answers) Extremely high blood glucose levels associeated with HHS cause high serum osmolality (normal 275-295 mOsm/kg). C indicates dehydration related to osmotic diuresis. D indicates hypotension related to water loss in HHS from osmotic diuresis where copious amounts of glucose are filtered into the urine and a huge fluid shift follows the urine. B is incorrect, in HHS blood glucose levels are 600-1200mg/dL. E is incorrect as this is a normal amount of urine output for 8 hours, in HHS polyuria occurs due to high glucose levels which lead to osmotic diuresis.
Which of the following may be warning signs for lung cancer? (Select all that apply) A. Dyspnea B. Dark yellow-colored sputum C. Persistent cough or change in cough D. Abdominal pain and frequent stools E. Recurring episodes of pleural effusion
A, C, and E
The nurse is formulating a teaching plan according to evidence-based breast cancer screening guidelines for a 50-year-old woman with low risk factors. Which diagnostic methods should be included in the plan? (Select all that apply.) A. Annual mammogram B. Magnetic resonance imaging (MRI) C. Breast ultrasound D. Breast self-awareness E. Clinical breast examination
A, D, and E
A nurse assesses a patient who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) A. Production of pink sputum B. Tracheal deviation C. Pain at insertion site D. Sudden onset of shortness of breath E. Drainage greater than 70 mL/hr F. Disconnection at Y site
B, D, E, and F D should raise concern for a pneumothorax
The nurse is planning to complete noon assessments on four assigned clients with Type 1 DM. All of the clients received subcutaneous insulin aspart at 0800 hours. Place the clients in the order of priority for the nurse's assessment. A. The 60 yo client who is nauseated and has just vomited for the second time. B. The 45 yo client who is dyspneic and has chest pressure and new onset atrial fibrillation. C. The 75 yo client with a fingerstick blood glucose reading of 300 mg/dL. D. The 50 yo client with a fingerstick blood glucose reading of 71mg/dL.
Answer B, A, C, D Remember your ABCs: B-The 45 yo with new chest pain and a rhythm change is the least stable. Diabetes increases risk for CAD and myocardial infarction. A-the nauseated patient is at risk for hypoglycemia if breakfast was not digested. C-the BG of 300 mg/dL is concerning but not life-threatening compared to A & B. D-this blood glucose is within normal range and is the most stable of all 4 patients. Continue with routine care.
A patient in the oncology clinic reports her family is frustrated at her ongoing fatigue 4 months after radiation therapy for breast cancer. What response by the nurse is most appropriate? A. "Are you getting adequate rest and sleep each day?" B. "It is normal to be fatigued even for years afterward." C. "This is not normal and I'll let the provider know." D. "Try adding more vitamins B and C to your diet."
B
A 20-year-old female client calls the nurse to report a lump she found in her breast. Which response is best for the nurse to provide? A. "Check it again in one month, and if it is still there schedule an appointment." B. Most lumps are benign, but it is always best to come in for an examination." C. "Try not to worry about it too much because usually most lumps are benign." D. "If you are in your menstrual period it is not a good time to check for lumps."
B
A client has cortisol deficiency and is being treated with prednisone (Deltasone). Which instruction by the nurse is most appropriate? A. "You will need to learn how to rotate the injection sites." B. "If you work outside when it's hot, you may need another drug." C. "Be sure to stay on your salt restriction even though it's difficult." D. "Take one tablet in the morning and two tablets at night to start."
B
A client who has been taking high-dose corticosteroid therapy for 1 month to treat a severe inflammatory condition, which has now resolved, asks the nurse why she needs to continue taking corticosteroids. Which is the nurse's best response? A. "It is possible for the inflammation to recur if you stop the drugs." B. "Once you start corticosteroids, you have to be weaned off them." C. "You must decrease the dose slowly so your hormones will begin to work again." D. "The drug suppresses your immune system, which needs to be built back up."
B
A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this client's teaching to prevent bloodborne infections? A. "Wash your hands after completing each test." B. "Do not share your monitoring equipment." C. "Blot excess blood from the strip with a cotton ball." D. "Use gloves when monitoring your blood glucose."
B
A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this client's teaching? A. "When ill, avoid eating or drinking to reduce vomiting and diarrhea." B. "Monitor your blood glucose levels at least every 4 hours while sick." C. "If vomiting, do not use insulin or take your oral antidiabetic agent." D. "Try to continue your prescribed exercise regimen even if you are sick."
B
A patient has a platelet count of 9800/mm3. What action by the nurse is most appropriate? A. Assess the patient for calf pain, warmth, and redness. B. Instruct the patient to call for help to get out of bed. C. Obtain cultures as per the facility's standing policy. D. Place the patient on protective isolation precautions.
B
A patient has received a dose of ondansetron (Zofran) for nausea. What action by the nurse is most important? A. Assess the patient for a headache. B. Assist the patient in getting out of bed. C. Instruct the patient to reduce salt intake. D. Weigh the patient daily before the patient eats.
B
A patient has returned from a transurethral resection of the prostate with a continuous bladder irrigation. Which action by the nurse is a priority if bright red urinary drainage and clots are noted 5 hours after the surgery? A. Review the hemoglobin and hematocrit as ordered. B. Take vital signs and notify the surgeon immediately. C. Release the traction on the three-way catheter. D. Remind the patient not to pull on the catheter.
B
A patient is concerned about the risk of lymphedema after a mastectomy. Which response by the nurse is best? A. "You do not need to worry about lymphedema since you did not have radiation therapy." B. "A risk factor for lymphedema is infection, so wear gloves when gardening outside." C. "Numbness, tingling, and swelling are common sensations after a mastectomy." D. "The risk for lymphedema is a real threat and can be very self-limiting."
B
A patient is having a catheter placed in the femoral artery to deliver yttrium-90 beads into a liver tumor. What action by the nurse is most important? A. Assessing the patient's abdomen beforehand B. Ensuring that informed consent is on the chart C. Marking the patient's bilateral pedal pulses D. Reviewing patient teaching done previously
B
A patient tells the oncology nurse about an upcoming vacation to the beach to celebrate completing radiation treatments for cancer. What response by the nurse is most appropriate? A. "Avoid getting salt water on the radiation site." B. "Do not expose the radiation area to direct sunlight." C. "Have a wonderful time and enjoy your vacation!" D. "Remember you should not drink alcohol for a year."
B
A patient with cancer has anorexia and mucositis, and is losing weight. The patient's family members continually bring favorite foods to the patient and are distressed when the patient won't eat them. What action by the nurse is best? A. Explain the pathophysiologic reasons behind the patient not eating. B. Help the family show other ways to demonstrate love and caring. C. Suggest foods and liquids the patient might be willing to try to eat. D. Tell the family the patient isn't able to eat now no matter what they bring.
B
After receiving the hand-off report, which patient should the oncology nurse see first? A. Patient who is afebrile with a heart rate of 108 beats/min B. Older patient on chemotherapy with mental status changes C. Patient who is neutropenic and in protective isolation D. Patient scheduled for radiation therapy today
B
An ACTH stimulation test is commonly used to diagnose: A. Grave's disease B. Adrenal insufficiency and Addison's disease C. Cystic fibrosis D. Hashimoto's disease
B
In 15 minutes you return to Mr. A's room and find that he is extremely lethargic, his skin is cold and clammy. He is no longer following commands. The patient's blood glucose is 38. What is the nurse's best action? A. Call a MET call and wait for them to arrive. B. Administer dextrose IV push STAT C. Ask the PCT to stay with the patient while you call the MD for new orders. D. Administer additional glucose tablets to Mr. A.
B
L.S., who is currently receiving chemotherapy, is concerned about developing oral mucositis. She asks the nurse what interventions may help prevent this painful side effect. The nurse list all of the following except: a. Switch to a soft bristled toothbrush b. Rinse with a strong alcohol based mouthwash c. Avoid tobacco d. Avoid hot, spicy or acidic foods
B
One of the benefits of Glargine (Lantus) insulin is its ability to: a. Release insulin rapidly throughout the day to help control basal glucose. b. Release insulin evenly throughout the day and control basal glucose levels. c. Simplify the dosing and better control blood glucose levels during the day. d. Cause hypoglycemia with other manifestation of other adverse reactions.
B
The 19 year old patient with type 1 diabetes calls the physician's office to discuss his self-monitoring blood glucose home reading. He is being tightly regulated with a combination of NPH and regular insulin before breakfast and supper. The past two mornings his blood glucose readings were 220 mg/dL and 210 mg/dL. Which of the following should the nurse tell the patient? a. "Continue with your medication regimen." b. "Check your blood glucose during the night." c. "Take your NPH insulin later in the evening." d. "Eat a bedtime snack earlier in the evening."
B
The newly diagnosed patient with Cushing's Disease will be at increased risk for A. Hypovolemia B. Falls and pathologic fractures C. Improved wound healing D. Hyponatremia
B
The newly diagnosed patient with Cushing's Disease will need dietary teaching that includes A. Potassium restriction B. Sodium and fluid restriction C. Decreased fiber intake D. High carbohydrate diet
B
The nurse evaluates the care provided to a patient hospitalized for treatment of adrenal crisis. Which of the following changes would indicate to the nurse that the patient is responding favorably to medical and nursing treatment? A. The patient's urinary output has increased. B. The patient's blood pressure has increased C. The patient has lost weight D. The patient's peripheral edema has decreased
B
The nurse is caring for a paitent who had an open radical prostatectomy. During the assessment, the nurse notes that the penis and scrotum are swollen. What does the nurse do next? A. Notify the health care provider B. Elevate the scrotum and penis, intermittently apply ice to the area for 24 to 48 hours C. Assist the patient to increase mobility D. Observe the urethral meatus for redness and discharge and monitor urine output.
B
The nurse understands hyposecretion of adrenal cortex hormones (gluco and mineralo-corticoids) from the adrenal gland, resulting in deficiency of the corticosteroid hormones; fatal if left untreated describes A. Diabetes Insipidus (DI) B. Addison's Disease C. Cushing's Disease D. SIADH
B
The nurse understands that a patient with Cushing's disease will have Dexamethasone suppression test results that show: A. A decrease in cortisol B. an continued increase in cortisol C. overproduction of ACTH D. underproduction of ACTH
B
The nurse understands that the patient admitted to the ICU with adrenal crisis will require replacement of: A. Hetastarch B. Glucose and Steroids C. Iodine D. Potassium
B
The patient care technician notifies you that the patient's Blood Glucose is < 62 mg/dl. The patient is NPO for a test. What is the nurse's best action(s)? Select all that apply. 1. Notify the MD and obtain an order to start an IV infusion of 5% dextrose in water (D5W). 2. Obtain an order to hold scheduled fast acting insulin. 3. Follow the adult Hypoglycemic protocol 4. Administer scheduled dose of Humulin R A. 1 & 2 B. 1, 2, & 3 C. 1, 2, 3, & 4 D. 1 & 4
B
When hydrocortisone (glucocorticoid replacement) use is discontinued, the nurse must recognize the possibility of what side effect, if this drug is stopped abruptly? A. Development of myxedema B. Circulatory collapse/Shock C. Development of Cushing's syndrome D. Development of diabetes insipidus
B
When preparing a patient with Addison's Disease for discharge which statement by the patient indicates a need for further teaching? A. "I understand that I need lifelong hormone replacement therapy." B. "During times of stress I may need to decrease my medication." C. "I must be careful not to injure myself." D. "I should always carry medical identification."
B
Which dietary alterations does the nurse make for a client with Cushing's disease? A. High carbohydrate, low potassium B. Low carbohydrate, low sodium C. Low protein, low calcium D. High carbohydrate, low potassium
B
Which of the following would be the most correct way to manage an accidental removal of a chest tube? A. Do nothing; it was probably ready to be removed. B. Quickly apply petroleum gauze dressing with occlusive tape, call the physician. C. Attempt to put the tube back into the incision site. D. Monitor the patient closely until the thoracic surgeon rounds in 4 hours.
B
While assessing a patient who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? A. Assess for drainage from the site. B. Cover the insertion site with sterile gauze. C. Contact the provider and obtain a suture kit. D. Reinsert the tube using sterile technique.
B
What might you see on a cardiac monitor for a patient in acute adrenal crisis? A. ST-elevation B. Peaked T waves C. Sinus arrhythmia D. Complete Heart Block
B (see doc for adrenal practice questions doc for actual picture of the peaked T waves)
A nurse is planning a teaching session with a patient on steroid therapy for the management of Addison's disease. Which of the following should be included in the teaching plan: A. Take on an empty stomach to decrease stomach upset. B. Carry an injectable form of drug in case of an emergency. C. Blood glucose may be lower because of the drug. D. There are no side effects to be expected with this drug.
B Part of the teaching plan would be to educate patient about carrying a labeled injectable form of the drug to prevent an Addisonian crisis. Steroids should be taken with food. Blood glucose usually rises with steroids.
A diabetic patient is started on intensive insulin therapy. The nurse will plan to teach the patient about mealtime coverage using _____ insulin. a. NPH b. lispro c. detemir d. glargine
B Rationale: Rapid or short acting insulin is used for mealtime coverage for patients receiving intensive insulin therapy. NPH, glargine, or detemir will be used as the basal insulin.
A patient with type 2 diabetes is scheduled for an outpatient coronary arteriogram. Which information obtained by the nurse when admitting the patient indicates a need for a change in the patient's regimen? a. The patient's most recent hemoglobin A1C was 6%. b. The patient takes metformin (Glucophage) every morning. c. The patient uses captopril (Capoten) for hypertension. d. The patient's admission blood glucose is 128 mg/dl.
B Rationale: To avoid lactic acidosis, metformin should not be used for 48 hours after IV contrast media are administered. The other patient data indicate that the patient is managing the diabetes appropriately.
The nurse is assessing a client's laboratory values following administration of chemotherapy. Which lab value leads the nurse to suspect that the client is experiencing tumor lysis syndrome (TLS)? A. Serum PTT of 10 seconds B. Serum calcium of 5 mg/dl C. Oxygen saturation of 90% D. Hemoglobin of 10 g/dl.
B TLS is associated with hypocalcemia
A postoperative patient on enteral nutrition has Continuous Tube Feeding placed on hold due to high residuals and severe nausea. The patient is receiving a Continuous intravenous infusion of regular insulin. What is the nurse's best action(s)? Select all that apply. A. Continue to current infusion of basal insulin B. Check blood glucose levels every hour. C. Consider reducing insulin dose and adding IVF containing glucose
B and C
A nurse assesses a patient who has a chest tube. For which manifestations should the nurse immediately intervene? (Select all that apply.) A. Production of pink sputum B. Tracheal deviation C. Sudden onset of shortness of breath D. Pain at insertion site E. Drainage of 75 mL/hr
B, C, and E
Clinical manifestations of Addison's Disease include: (select all that apply) A. Weight gain B. Progressive weakness C. Skin hyperpigmentation D. Hypertension E. Decreased axillary and pubic hair
B, C, and E
A 70-year-old patient returned from a transurethral resection of the prostate 8 hours ago with a continuous bladder irrigation. The nurse reviews his laboratory results as follows: Sodium: 128 mEq/L Hemoglobin: 14 g/dL Hematocrit: 42% RBC count: 4.5 What action by the nurse is the most appropriate? A. Consider starting a blood transfusion. B. Slow down the bladder irrigation if the urine is pink. C. Report the findings to the surgeon immediately. D. Take the vital signs every 15 minutes.
B. Sodium level is low. Risk for fluid overload and worsening hyponatremia. Slow fluids. Pink urine indicates decreased bleeding, if the urine was still red with clots you could not decrease the irrigation rate.
A 35-year-old woman is diagnosed with stage III breast cancer. She seems to be extremely anxious. What action by the nurse is best? A. Encourage the patient to search the Internet for information tonight. B. Ask the patient if sexuality has been a problem with her partner. C. Explore the idea of a referral to a breast cancer support group. D. Assess whether there has been any mental illness in her past
C
A 55-year-old African-American patient is having a visit with his health care provider. What test should the nurse discuss with the patient as an option to screen for prostate cancer, even though screening is not routinely recommended? A. Complete blood count B. Culture and sensitivity C. Prostate-specific antigen D. Cystoscopy
C
A client on hormone replacement medication after a bilateral adrenalectomy calls the clinic asking to be seen for "stomach flu" with nausea and vomiting. Which response by the nurse is best? A. "I will call in a prescription for an antiemetic medication for you." B. "Try to drink extra fluids until you can come in for an appointment." C. "You need to go to the nearest emergency department today." D. "Double the dose of your medication today and tomorrow."
C
A client with early breast cancer receives the results of a breast biopsy and asks the nurse to explain the meaning of staging and the type of receptors found on the cancer cells. Which explanation should the nurse provide? A. Lymph node involvement is not significant. B. Small tumors are aggressive and indicate poor prognosis. C. The tumor's estrogen receptor guides treatment options. D. Stage I indicates metastasis.
C
A nurse has taught a patient about dietary changes that can reduce the chances of developing cancer. What statement by the patient indicates the nurse needs to provide additional teaching? A. "Foods high in vitamin A and vitamin C are important." B. "I'll have to cut down on the amount of bacon I eat." C. "I'm so glad I don't have to give up my juicy steaks." D. "Vegetables, fruit, and high-fiber grains are important."
C
A nurse is admitting a client with a diagnosis of Addison's disease to the hospital. On assessment, the nurse would expect to note which finding that is a manifestation of this disorder? A. peripheral edema B. excessive facial hair C. lower than normal blood glucose level D. high blood pressure
C
A patient comes to the emergency department with a complain of nausea, vomiting, and abdominal pain. She is a type 1 diabetic. Four days earlier, she reduced her insulin dose due to flu symptoms and decreased nutritional intake. The nurse performs an assessment of the patient that reveals poor skin turgor, dry mucous membranes, and fruity breath odor. The nurse should suspect which of the following problems? a. Hypoglycemia b. Viral illness c. Diabetic Ketoacidosis d. Hyperglycemic Hyperosmolar State
C
A patient has just returned from a right radical mastectomy. Which action by the unlicensed assistive personnel (UAP) would the nurse consider unsafe? A. Checking the amount of urine in the urine catheter collection bag B. Elevating the right arm on a pillow C. Taking the blood pressure on the right arm D. Encouraging the patient to squeeze a rolled washcloth
C
A patient is admitted with superior vena cava syndrome. What action by the nurse is most appropriate? A. Administer a dose of allopurinol (Aloprim). B. Assess the patient's serum potassium level. C. Gently inquire about advance directives. D. Prepare the patient for emergency surgery.
C
A patient is having pain resulting from bone metastases caused by lung cancer. What is the most effective intervention for relieving the patient's pain? A. Support the patient through chemotherapy B. Handle and move the patient gently C. Administer analgesics around the clock D. Reposition the patient, use distraction
C
A patient is receiving rituximab (Rituxan) and asks how it works. What response by the nurse is best? A. "It causes rapid lysis of the cancer cell membranes." B. "It destroys the enzymes needed to create cancer cells." C. "It prevents the start of cell division in the cancer cells." D. "It sensitizes certain cancer cells to chemotherapy."
C
A patient is starting hormonal therapy with tamoxifen (Nolvadex) to lower the risk for breast cancer. What information needs to be explained by the nurse regarding the action of this drug? A. It blocks the release of luteinizing hormone. B. It interferes with cancer cell division. C. It selectively blocks estrogen in the breast. D. It inhibits DNA synthesis in rapidly dividing cells.
C
Four patients are receiving tyrosine kinase inhibitors (TKIs). Which of these four patients should the nurse assess first? A. Patient with dry, itchy, peeling skin B. Patient with a serum calcium of 9.2 mg/dL C. Patient with a serum potassium of 2.8 mEq/L D. Patient with a weight gain of 0.5 pound (1.1 kg) in 1 day
C
In primary hyperaldosteronism, the nurse expects the laboratory results to indicate a decreased serum level of which electrolyte? A. Sodium B. Antidiuretic hormone C. Potassium D. Glucose
C
The nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse would expect to find: A. Hypotension B. Thick, coarse skin C. Truncal obesity D. Weight gain in the arms and legs
C
The nurse is caring for a patient with lung cancer who states, "I don't want any pain medication because I am afraid I'll become addicted." How should the nurse respond? A. "I will ask the provider to change your medication to a drug that is less potent." B. "Would you like me to use music therapy to distract you from your pain?" C. "It is unlikely you will become addicted when taking medicine for pain." D. "Would you like me to give you acetaminophen (Tylenol) instead?"
C
The nurse teaches the patient that the best time to take corticosteroids for replacement purposes is A. Once per day at bedtime B. Every other day C. On arising in the morning and in the late afternoon D. At consistent intervals every 6-8 hours
C
Glucocorticoids such as cortisol hormone help regulate all of the following EXCEPT: A. Cardiac muscle responsiveness/excitability B. Carbohydrate and fat metabolism C. Immune function D. Alveoli perfusion
D
What comfort measure can only be performed by a nurse, as opposed to an unlicensed assistive personnel (UAP), for a patient who returned from a left modified radical mastectomy 4 hours ago? A. Placing the head of bed at 30 degrees B. Elevating the left arm on a pillow C. Administering morphine for pain at a "4" on a 0-to-10 scale D. Supporting the left arm while initially ambulating the patient
C
Which client statement indicates the need for clarification regarding the instructions for collecting a 24-hour urine specimen for assessment of endocrine function? A. "I will continue to take all my prescribed medicine during the test." B. "I will add the preservative to the container at the beginning of the test." C. "I will start the collection by saving the first urine of the morning." D. "At the end of 24 hours, I will urinate and save that last specimen."
C
Which finding in a female patient by the nurse would receive the highest priority of further diagnostics? A. Tender moveable masses throughout the breast tissue B. A 3-cm firm, defined mobile mass in the lower quadrant of the breast C. Nontender immobile mass in the upper outer quadrant of the breast D. Small, painful mass under warm reddened skin
C
Which safety measure is most important for the nurse to institute for a client who has Cushing's disease? A. Pad the siderails of the client's bed. B. Assist the client to change positions slowly. C. Use a lift sheet to change the client's position. D. Keep suctioning equipment at the client's bedside.
C
A patient has a chest tube in place. What does the water in the water seal chamber do when the system is functioning correctly? A. Bubbles vigorously and continuously B. Bubbles gently and continuously C. Fluctuates with the patient's respirations D. Stops fluctuation, and bubbling is not observed
C (Answer choice A is indicative of an air leak and is incorrect)
A patient is admitted to the emergency room in Adrenal/Addisonian crisis (adrenal insufficiency).Which of the following is not a priority intervention at this time? A. Replacing fluids with normal saline (NS). B. Administering dextrose immediately. C. Weighing the patient. D. Administering intravenous steroids.
C Adrenal crisis is a life-threatening medical emergency. The priority at this time is to restore fluid volume (with NS), to replace steroids and increase blood glucose. While weighing the patient is an intervention in a person with adrenal insufficiency, it is not a priority at this time.
A nurse is providing discharge teaching to a patient who has had both adrenal glands removed. Which of the following discharge instructions correctly reflects a governing principle about the administration and dosing of glucocorticoids? A. Anticipate a gradual decrease in the medication dose as the adrenal gland slowly resumes function. B. Avoid elective surgical procedures and emotional stress. C. Adjust steroid dosing in time of physical and emotional distress. D. Stop taking the medication after the first thirty post-op days.
C After a bilateral adrenalectomy, patients will be placed on lifelong glucocorticoids. Dosages should be adjusted in the presence of increased stressors such as fever, infection, dental work or stress. Elective surgery can be done with dosage adjustment.
A client with type 2 diabetes who also has heart failure is prescribed metformin extended release (Glucophage XR) one daily. On assessment, the nurse finds that the client now has muscle aches, drowsiness, low blood pressure, and slow irregular heartbeat. What is the nurse's best action? A. Assess the patient's blood glucose level and prepare to administer IV glucose. B. Reassure the patient that these symptoms are normal effects of the drug. C. Hold the dose and notify the prescriber immediately. D. Administer the drug at bedtime to prevent falls.
C Because of concern for lactic acidosis
The clinic nurse is evaluating a client with type 1 DM who intends to enroll in a tennis class. Which statement made by the client indicates the client understands the effects of exercise on insulin demand? A. "I will carry a high-fat, high calorie food such as a cookie." B. "I will administer 1 unit of lispro insulin prior to playing tennis." C. "I will eat a 15-gram carb snack before playing tennis." D. "I will need to rest for a while during tennis if I feel sweaty or shaky."
C Exercise without sufficient carbohydrates can result in unexpected hypoglycemia. A-avoid a high fat food, B-insulin without food prior to exercise=hypoglycemia, D-symptoms of hypoglycemia.
A nurse cares for a patient who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this patient? A. Spaghetti with meat sauce, ice cream B. Chicken soup, grilled cheese sandwich C. Omelet, soft whole wheat bread D. Pasta salad, custard, orange juice
C Perfect meal to decrease risk of aspiration and trauma
A home health nurse is assessing a patient who is currently being treated for Addison's disease. Which of the following findings best indicate to this nurse that the patient may need to have his dose of glucocorticoids decreased? A. Fragile skin and clubbing of the fingers. B. Exophthalmos (bulging eyes) and dry skin. C. Weight gain, hypertension, and hyperglycemia. D. Weight loss and hypoglycemia.
C Weight gain and hyperglycemia may be an indicator of excess of glucocorticoids. The nurse would contact the MD or NP to review the symptoms.
A patient is being evaluated for Cushing's Syndrome. The nurse plans to draw a blood sample to determine cortisol level at its peak. When is the best time to draw the sample? A. 15 minutes before and 15 minutes after first meal of the day. B. Within 2 hours of a high protein, high sodium meal C. Between 6am-8am in the morning D. 30 minutes before and 30 minutes after the first meal of the day.
C the best time to draw Cortisol level at its peak is between 6a and 8a for most people.
The nurse determined that the fluid volume deficit associated with HHS has resolved. Which serum laboratory finding led the nurse to this conclusion? (Tip the question is asking about the fluid volume deficit specifically, not the hyperglycemia. Read the question carefully to clearly identify what is being asked). A. Decreased glucose B. Decreased sodium C. Decreased serum osmolality D. Decreased potassium
C HHS causes a profound fluid volume deficit related to osmotic diuresis. A normalizing serum osmolality means that the fluid volume deficit is resolving. A decreased glucose means the hyperglycemia is resolving not the fluid volume deficit
Two hours after taking a regular morning dose of regular insulin, the client presents to a clinic visit with diaphoresis, tremors, palpitations, and tachycardia. Which nursing action is most appropriate? A. Check pulse oximetry: if 94% or less, start oxygen at 2L per nasal cannula. B. Give a baby aspirin and one nitroglycerin tablet, obtain a 12-lead EKG C. Check blood glucose level; provide carbohydrates if less than 70 mg/dL D. Check heart rate; if HR is above 120 bpm, give atenolol 25 mg by mouth
C Regular insulin (Humulin R) peaks in 2-4 hours after administration=the most likely time for hypoglycemia to occur. The client's symptoms suggest hypoglycemia, so a blood level should be checked and carbs given if low.
The 64-year-old patient has experienced multiple episodes of hyperglycemia not controlled by subcutaneous insulin injections. The patient has an active order for infusion of an insulin drip for glycemic management to be discontinued at bedtime, after which the patient is NPO. The patient's most recent blood glucose level, taken at 3 P.M. was 60 mg/dL. Which of the following actions by the nurse is the MOST appropriate? (p.146) a. The nurse should follow the order and allow the insulin to infuse until bedtime. b. The nurse should recheck the patient's blood glucose level. c. The nurse should bring this blood glucose level to the attention of the MD and discuss stopping the infusion. d. The nurse should seek advice from other nurses.
C. Rationale: The blood glucose is now low and continuing the insulin infusion has the potential to drop the glucose to a dangerous level
A patient receives 10 units of NPH insulin every morning at 8 A.M. At 4 P.M. the nurse observes that the patient is diaphoretic and confused. The nurse should take which of the following actions FIRST? a. Check vital signs b. Check urine for ketones and glucose c. Give 6 oz. of skim milk and 2 graham crackers d. Call the physician
C. Rationale: These are S/S of hypoglycemia. Give fast acting sugar and protein, recheck blood glucose in 15 minutes.
The nurse is designing a diet plan for a 80-year old with poorly fitting dentures who has recently been diagnosed with type 2 diabetes mellitus. The nurse knows that which of the following is the LEAST likely risk to the patient? (p.163) a. Malnutrition b. Dehydration c. Hyperglycemia d. Low blood sugar
C. Rationale: the patient has difficulty taking in enough nutrition. This patient is more likely to have hypoglycemia rather than hyperglycemia.
Cushing's Syndrome may be caused by which of the following? A. Destruction of more than 90% of the adrenal gland B. Thyroid hormone overproduction C. Glucocorticoid excess D. Insufficient antidiuretic hormone
C? Cushing's is too much cortisol
A client with hypercortisolism has an irregular pulse. Which is the nurse's priority intervention? A. Documenting the finding and reassessing in 1 hour B. Assessing blood pressure in both arms C. Administering atropine sulfate D. Assessing the telemetry reading
D
A new nurse has been assigned a patient who is in the hospital to receive iodine-131 treatment. Which action by the nurse is best? A. Ensure the patient is placed in protective isolation. B. Hand off a pregnant patient to another nurse. C. No special action is necessary to care for this patient. D. Read the policy on handling radioactive excreta.
D
A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? A. Administration of oxygen via ventilator B. Intravenous administration of 10% glucose C. Implementation of seizure precautions D. Administration of intravenous insulin
D
A nurse cares for a patient who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? A. Ambulate the patient in the hallway to promote deep breathing. B. Auscultate the patient's anterior and posterior lung fields. C. Encourage the patient to take shallow breaths to help with the pain. D. Administer pain medication and encourage the patient to take deep breaths.
D
A nurse cares for a patient who has a chest tube. When would this patient be at highest risk for developing a pneumothorax? A. When the insertion site becomes red and warm to the touch B. When the tube drainage decreases and becomes sanguineous C. When the patient experiences pain at the insertion site D. When the tube becomes disconnected from the drainage system
D
A nurse cares for a patient who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment? A. Strip the tubing to minimize clot formation and ensure patency. B. Secure tubing junctions with clamps to prevent accidental disconnections. C. Connect the chest tube to wall suction at the level prescribed by the provider. D. Keep padded clamps at the bedside for use if the drainage system is interrupted.
D
A nurse is assessing a female patient who is taking progestins. What assessment finding requires the nurse to notify the provider immediately? A. Irregular menses B. Edema in the lower extremities C. Ongoing breast tenderness D. Red, warm, swollen calf
D
A nurse is assessing a patient with glioblastoma. What assessment is most important? A. Abdominal palpation B. Abdominal percussion C. Lung auscultation D. Neurologic examination
D
A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which should alert the nurse to intervene immediately? A. Serum chloride level of 98 mmol/L B. Serum calcium level of 8.8 mg/dL C. Serum sodium level of 132 mmol/L D. Serum potassium level of 2.5 mmol/L
D
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. "Examine your feet using a mirror every day." B. "Rotate your insulin injection sites every week." C. "Check your blood glucose level before each meal." D. "Use a bath thermometer to test the water temperature.
D
A nurse works with patients who have alopecia from chemotherapy. What action by the nurse takes priority? A. Helping patients adjust to their appearance B. Reassuring patients that this change is temporary C. Referring patients to a reputable wig shop D. Teaching measures to prevent scalp injury
D
A patient diagnosed with lung cancer asks the nurse why he must be careful of large crowds and people who are ill. What is the nurses' best response? A. "With lung cancer, you are more likely to develop pneumonia and could pass this on to other people who are ill." B. "When lung cancer is in the bones, it becomes a bone marrow malignancy, which stops producing immune cells." C. "The large amount of mucus produced by cancer cells is a good breeding ground for bacteria and other microorganisms." D. "When lung cancer is in the bones, it can prevent production of immune cells making you less resistant to infection."
D
A patient is in the oncology clinic for a first visit since being diagnosed with cancer. The nurse reads in the patient's chart that the cancer classification is TISN0M0. What does the nurse conclude about this patient's cancer? A. The primary site of the cancer cannot be determined. B. Regional lymph nodes could not be assessed. C. There are multiple lymph nodes involved already. D. There are no distant metastases noted in the report.
D
A patient with Addison's disease asks a nurse for nutrition and diet advice. Which of the following diet modification is NOT recommended? A. A diet high in grains B. A diet with adequate caloric intake C. A high protein diet D. A restricted sodium diet
D
A patient with cancer is admitted to a short-term rehabilitation facility. The nurse prepares to administer the patient's oral chemotherapy medications. What action by the nurse is most appropriate? A. Crush the medications if the patient cannot swallow them. B. Give one medication at a time with a full glass of water. C. No special precautions are needed for these medications. D. Wear personal protective equipment when handling the medications.
D
After administering glucose tablets to Mr. A when will you recheck his BG level? A. 0600am B. 45 minutes C. 60 minutes D. 15 minutes
D
All of the following are symptoms of Cushing's syndrome except: A. Severe fatigue and weakness B. Hypertension and elevated blood glucose C. A protruding hump between the shoulders D. Axilla and chest hair loss
D
An important intervention when caring for a patient with Cushing syndrome is to A. Restrict protein intake B. Observe for signs of hypotension C. Administer medication only as needed D. Protect the patient from exposure to infection
D
At 0300 Mr. A calls you into his room c/o sweating, nausea, and "shakiness." You establish that Mr. A's BG is 48. Mr. A is alert and able to swallow. What is your next action? A. Administer glucagon IM injection stat. B. Stay with the patient and wait for the MET team to arrive. C. Mr. A is alert, recheck his blood glucose in 1 hour. D. You administer 4 glucose tablets.
D
During dressing changes, the nurse assesses a patient who has had breast reconstruction. Which finding would cause the nurse to take immediate action? A. Slightly reddened incisional area B. Blood pressure of 128/75 mm Hg C. Temperature of 99° F (37.2° C) D. Dusky color of the flap
D
Mr. George is newly diagnosed with lung cancer. Prior to surgery, Mr. George must undergo external beam radiation therapy to shrink the tumor to an operable size. The nurse understands that skin care for a patient receiving radiation therapy includes all of the following except: A. Wash irradiate skin gently with water or mild soap each day B. Avoid sun exposure C. Do not remove ink or dye markings that ID where radiation is to be focused D. Apply generic powders and lotions to the radiated skin areas to decrease inflammation
D
The nurse assesses a patient with a history of Addison's disease who has received steroid therapy for several years. The nurse could expect the client to exhibit which of the following changes in appearance? A. Buffalo hump, girdle/truncal obesity, gaunt facial features B. Tanning of the skin, discoloration of the mucous membranes, alopecia, weight loss C. Emaciation, nervousness, breast engorgement, hirsutism D. Truncal obesity, purple striations on the skin, moon face
D
The nurse has taught a patient with cancer ways to prevent infection. What statement by the patient indicates that more teaching is needed? A. "I should take my temperature daily and when I don't feel well." B. "I will wash my toothbrush in the dishwasher once a week." C. "I won't let anyone share any of my personal items or dishes." D. "It's alright for me to keep my pets and change the litter box."
D
The nurse is administering hydrocortisone (Cortef) for a patient with adrenal insufficiency. The nurse understands that all of the following are important to the administration of the medication EXCEPT A. Take the medication with food B. Avoid the deltoid muscle for IM routes C. The medication may mask signs of infection D. The patient will not require blood glucose monitoring
D
The orientee understands that risk factors of metabolic syndrome include: Select all that apply. 1) High triglycerides 2) Low LDL cholesterol 3) Low HDL cholesterol 4) Large waist circumference 5) Impaired glucose tolerace (FPG>100 mg/dL) 6) Blood pressure >130/85 A. 1, 2, 3, 4, 5, 6 B. 2, 3, 5, 6 C. 1, 2, 3, 4, 5 D. 1, 3, 4, 5, 6
D
Which of the following conditions is caused by long-term exposure to high levels of cortisol? A. Addison's disease B. Crohn's disease C. Adrenal insufficiency D. Cushing's syndrome
D
Upon observation of a chest tube set-up, the nurse reports to the provider that there is a leak in the chest tube and system. How has the nurse identified this problem? A. Drainage in the collection chamber is decreased B. The bubbling in the suction chamber has suddenly increased C. Fluctuation in the water seal chamber has stopped D. There was onset of continuous bubbling in the water seal chamber
D (Answer choice C indicates that the tube is kinked or clamped because air is no longer flowing smoothly and is incorrect)
A nurse is writing a plan of care for a patient newly admitted with Addison's disease. Nursing diagnoses might include: A. Altered mobility. B. Altered nutrition, more than body requirements. C. Fluid volume excess. D. Risk for injury related to potential hypoglycemia.
D A patient with Addison's disease can rapidly lose fluids and develop signs and symptoms of hypovolemic shock, including hypotension, hypoglycemia, fatigue and nausea.
The client ate 45 grams of carbohydrates (carbs) with the dinner meal. The client is to receive 2 units of aspart insulin subcutaneously for each carb choice (CHO) eaten (1 carb choice=15 grams). Which syringe shows the correct amount of insulin that the nurse should administer? A. Syringe with 15 units B. Syringe with 30 units C. Empty syringe D. Syringe with 6 units
D Answer: The client should receive 6 units of insulin (illustration #4). Eating 45 grams of carbs equals 3 CHOs. If the client is to receive 2 units of insulin for each CHO, the total amount of aspart insulin Is 3 CHO times 2 units per CHO=6 units.
The nurse obtains a fingerstick blood glucose reading of 48mg/dL for the client with Type 1 DM. The client is to receive 6 units of regular and 10 units of NPH insulin now. Which is the nurse's best immediate intervention? (Tip: assume the patient is alert for this question). A. Administer the insulin that is due now. B. Call the lab for a STAT serum glucose level. C. Have the client choose foods for a meal now. D. Provide juice with 15 grams of carbohydrates now.
D Normal BG level is 70-110 mg/dL. Hypoglycemia is treated with 15 g of a simple (fast acting) carb, such as 4-6 oz of fruit juice of 8 oz of low-fat milk. Focus on the issue: interventions for a low blood glucose.
The nurse is reviewing information for the client with Type 1 DM. The nurse concludes that the client may be experiencing Somogyi's phenomenon, as evidence by which finding? A. 0200 blood glucose between 80-110 mg/dL and morning levels between 80-100mg/dL B. 0200 blood glucose between 50-60 mg/dL and morning levels between 48-62 mg/dL C. 0200 blood glucose between 130-140 mg/dL and morning levels between 180-200 mg/dL D. 0200 blood glucose between 45-62 mg/dL and morning levels between 200-305 mg/dL
D The nurse should conclude that a low blood glucose in the middle of the nigh and a rebound hyperglycemia are signs of Somogyi's phenomenon, also known as Somogyi's effect. Always associate Somogyi's with a rebound effect (a low, then a high).
A nurse and an unlicensed assistive personnel (UAP) are caring for a patient with an open radical prostatectomy. Which comfort measure could the nurse delegate to the UAP? A. Administering an antispasmodic for bladder spasms B. Managing pain through patient-controlled analgesia C. Applying ice to a swollen scrotum and penis D. Helping the patient transfer from the bed to the chair
D. The BEST response is D assisting with mobility. A and B are nursing duties. C would also be a nursing duty upon initiation because assessment of the area is required.
L.S. is a 44 year old patient with breast cancer who is receiving chemotherapy. The patient develops thrombocytopenia and is at risk for bleeding. The nurse implements all of the following interventions to decrease the patient's risk of injury except: A. Fall precautions and gentle position changes B. Use a lift sheet to reposition the patient C. Minimize blood draws D. Avoid rectal trauma E. Encourage the patient to resume playing soccer and other contact sports
E
Which of these laboratory values noted by the nurse when reviewing the chart of a diabetic patient indicates the need for further assessment of the patient? a. Fasting blood glucose of 130 mg/dl b. Noon blood glucose of 52 mg/dl c. Glycosylated hemoglobin of 6.9% d. Hemoglobin A1C of 5.8%
b. Noon blood glucose of 52 mg/dl The nurse should assess the patient with a blood glucose level of 52 mg/dl for symptoms of hypoglycemia, and give the patient some carbohydrate-containing beverage such as orange juice. The other values are within an acceptable range for a diabetic patient.
