MS2 Comprehensive EAQ
A nurse is caring for a client who was recently diagnosed with hyperparathyroidism. Which statement by the client indicates the need for additional discharge teaching? a. "I will increase my fluid and calcium intake." b. "I will take my pain medications according to the schedule we developed." c. "I'll call my physician if I notice tingling around my lips." d. "I'll schedule a follow-up visit with my physician as soon as I get home."
a. "I will increase my fluid and calcium intake." The client requires additional teaching if he states that he will increase his calcium intake. Hyperparathyroidism causes extreme increases in serum calcium levels. The client should increase his fluid intake, but he should limit his calcium and vitamin D intake. The client should continue to take pain mediations as scheduled and have regular follow-up visits with his physician. Tingling around the lips is a sign of hypercalcemia and should be reported to the physician immediately.
The nurse is providing care for a client with a diagnosis of hypertension. The nurse should consequently assess the client for signs and symptoms of which other health problem? a. Atherosclerosis b. Migraines c. Atrial-septal defect d. Thrombocytopenia
a. Atherosclerosis Hypertension is both a sign and a risk factor for atherosclerotic heart disease. It is not associated with structural cardiac defects, low platelet levels, or migraines.
The nurse is providing health education for a male patient who is preparing to be discharged home following a recovery from total hip replacement surgery. When reviewing the guidelines for safe mobility and positioning to prevent injury, the nurse should teach the patient to: a. Avoid crossing his legs for the next several months. b. Perform sit-ups to build core muscle strength. c. Perform stair-climbing to build muscle strength. d. Resume normal sexual activity after waiting 1 week.
a. Avoid crossing his legs for the next several months. At no time during the first 4 months should the patient cross the legs or flex the hip more than 90 degrees. Sexual intercourse can be resumed based upon surgeon recommendation (typically 3 to 6 months postoperatively). Stair-climbing is permitted as prescribed but is kept to a minimum for 3 to 6 months.
A nurse is teaching a client with osteomalacia about the role of diet. What would be the best choice for breakfast for a client with osteomalacia? a. Cereal with milk, a scrambled egg, and grapefruit b. Poached eggs with sausage and toast c. Waffles with fresh strawberries and powdered sugar d. A bagel topped with butter and jam with a side dish of grapes
a. Cereal with milk, a scrambled egg, and grapefruit The best meal option is the one that contains the highest dietary sources of calcium and vitamin D. The best selection among those listed is cereal with milk, and eggs, as these foods contain calcium and vitamin D in a higher quantity over the other menu options.
A client is admitted to the orthopedic unit with a fractured femur after a motorcycle accident. The client has been placed in traction until the femur can be rodded in surgery. For what early complication(s) should the nurse monitor this client? Select all that apply. a. Compartment syndrome b. Systemic infection c. Fat embolism d. Complex regional pain syndrome e. Deep vein thrombosis
a. Compartment syndrome c. Fat embolism e. Deep vein thrombosis Early complications include shock, fat embolism, compartment syndrome, and venous thromboemboli (deep vein thrombosis [DVT], pulmonary embolism [PE]). Infection and complex regional pain syndrome are later complications of fractures.
The nurse is assessing a client's knee. The area has a grating sensation. What would this be documented as? a. Crepitus b. Dislocation c. False motion d. Shortening
a. Crepitus When palpation of the extremity reveals a grating sensation, this is called crepitus. It is caused by the rubbing of the bone fragments against each other. In fractures of long bones, there is actual shortening of the extremity because the contraction of the muscles that are attached distal and proximal to the site of the fracture. Abnormal movement is false motion. With dislocation of a joint, the articular surfaces of the bones forming the joint are not longer in anatomic alignment
A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes? a. Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) b. Random plasma glucose greater than 126 mg/dL (7.0 mmol/L) c. Random plasma glucose greater than 150 mg/dL (8.3 mmol/L) d. Fasting plasma glucose greater than 116 mg/dL (6.4 mmol/L) on two separate occasions
a. Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L), or a fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L).
An older adult client with type 2 diabetes is brought to the emergency department by the client's daughter. The client is found to have a blood glucose level of 600 mg/dL (33.3 mmol/L). The client's daughter reports that the client recently had a gastrointestinal virus and has been confused for the last 3 hours. The diagnosis of hyperglycemic hyperosmolar syndrome (HHS) is made. What nursing action would be a priority? a. Fluid and electrolyte replacement b. Administering sodium bicarbonate intravenously c. Reversing acidosis by administering insulin d. Administration of antihypertensive medications
a. Fluid and electrolyte replacement The overall approach to HHS includes fluid replacement, correction of electrolyte imbalances, and insulin administration. Antihypertensive medications are not indicated, as hypotension generally accompanies HHS due to dehydration. Sodium bicarbonate is not given to clients with HHS, as their plasma bicarbonate level is usually normal. Insulin administration plays a less important role in the treatment of HHS because it is not needed for reversal of acidosis, as in diabetic ketoacidosis (DKA).
The nurse is assessing a client suspected of having developed acute glomerulonephritis. The nurse should expect to address what clinical manifestation that is characteristic of this health problem? a. Hematuria b. Glucosuria c. Hypotension unresolved by fluid administration d. Precipitous decrease in serum creatinine levels
a. Hematuria The primary presenting feature of acute glomerulonephritis is hematuria (blood in the urine), which may be microscopic (identifiable through microscopic examination) or macroscopic or gross (visible to the eye). Proteinuria, primarily albumin, which is present, is due to increased permeability of the glomerular membrane. Blood urea nitrogen (BUN) and serum creatinine levels may rise as urine output drops. Glucosuria does not normally accompany glomerulonephritis, and hypertension is much more likely than hypotension.
A client with a documented history of seizure disorder experiences a generalized seizure. What nursing action is most appropriate? a. Loosen the client's restrictive clothing. b. Restrain the client to prevent injury. c. Place client in high Fowler position. d. Open the client's jaws to insert an oral airway.
a. Loosen the client's restrictive clothing. An appropriate nursing intervention would include loosening any restrictive clothing on the client. No attempt should be made to restrain the client during the seizure because muscular contractions are strong and restraint can produce injury. Do not attempt to pry open jaws that are clenched in a spasm to insert anything. Broken teeth and injury to the lips and tongue may result from such an action. If possible, place the client on one side with head flexed forward, which allows the tongue to fall forward and facilitates drainage of saliva and mucus.
During the admission assessment of an HIV-positive patient whose CD4+ count has recently fallen, the nurse carefully assesses for signs and symptoms related to opportunistic infections. What is the most common life-threatening infection? a. Pneumocystis pneumonia b. Clostridium difficile c. Mycobacterium tuberculosis d. Salmonella infection
a. Pneumocystis pneumonia There are a number of opportunistic infections that can infect individuals with AIDS. The most common life-threatening infection in those living with AIDS is Pneumocystis pneumonia (PCP), caused by P. jiroveci (formerly carinii). Other opportunistic infections may involve Salmonella, Mycobacterium tuberculosis, and Clostridium difficile.
A client with primary hypertension reports dizziness with ambulation when taking the prescribed alpha-adrenergic blocker. When teaching this client, what should the nurse emphasize? a. Rising slowly from a lying or sitting position b. Taking medication first thing in the morning c. Increasing fluids to maintain BP d. Stopping medication if dizziness persists
a. Rising slowly from a lying or sitting position Clients who experience postural hypotension should be taught to rise slowly from a lying or sitting position and use a cane or walker if necessary for safety. It is not necessary to teach these clients about increasing fluids or taking medication in the morning (this would increase the effects of dizziness). Clients should not be taught to stop the medication if dizziness persists because this is unsafe and beyond the nurse's scope of practice.
A client who experienced a large upper gastrointestinal (GI) bleed due to gastritis has had the bleeding controlled and is now stable. For the next several hours, the nurse caring for this client should assess for what signs and symptoms of recurrence? a. Tachycardia, hypotension, and tachypnea b. Tarry, foul-smelling stools c. Sudden thirst, unrelieved by oral fluid administration d. Diaphoresis and sudden onset of abdominal pain
a. Tachycardia, hypotension, and tachypnea Tachycardia, hypotension, and tachypnea are signs of recurrent bleeding. Clients who have had one GI bleed are at risk for recurrence. Tarry stools are expected short-term findings after a hemorrhage. Hemorrhage is not normally associated with sudden thirst or diaphoresis.
For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? a. Using a Venturi mask to deliver oxygen as ordered b. Keeping the client in semi-Fowler's position c. Administering a sedative as ordered e. Encouraging the client to drink three glasses of fluid daily
a. Using a Venturi mask to deliver oxygen as ordered The client with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily wouldn't affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Clients with COPD and respiratory distress should be placed in high Fowler's position and shouldn't receive sedatives or other drugs that may further depress the respiratory center.
A nurse is working with a 10-year-old client who is undergoing a diagnostic workup for suspected asthma. Which signs and symptoms are consistent with a diagnosis of asthma? Select all that apply. a. Wheezing b. Cough c. Chest tightness d. Bradypnea e. Crackles
a. Wheezing b. Cough c. Chest tightness Asthma is a chronic inflammatory disease of the airways that causes airway hyperresponsiveness, mucosal edema, and mucus production. This inflammation ultimately leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheezing, and dyspnea. Crackles and bradypnea are not typical symptoms of asthma.
A nurse who provides care for numerous older adults is aware of the high incidence and prevalence of benign prostatic hyperplasia (BPH) among older men. Which of the following statements by patients is suggestive of BPH? a. "The last few days, I have a dull ache in my testicles sometimes." b. "I find that I have to get up three or four times each night to go to the bathroom." c. "I found a creamy white discharge at the end of my penis yesterday." d. "After I have an orgasm, I have throbbing pain for the next few minutes."
b. "I find that I have to get up three or four times each night to go to the bathroom." Nocturia is a common sign of BPH. Pain after orgasm, penile discharge, and testicular pain are not typical manifestations of BPH.
The nurse is caring for a client whose acute kidney injury (AKI) resulted from a prerenal cause. Which condition most likely caused this client's health problem? a. Pregnancy b. Burns c. Glomerulonephritis d. Ureterolithiasis
b. Burns AKI has categories that identify causation. These are prerenal, intrarenal, and postrenal. Prerenal AKI results from hypoperfusion of the kidney caused by volume depletion. Common causes are burns, hemorrhage, gastrointestinal losses, sepsis, and shock. Glomerulonephritis and ureterolithiasis (kidney stones) are associated with intrarenal causes. Pregnancy is linked to postrenal AKI (obstructions distal to the kidney).
A client with end-stage kidney disease is scheduled to begin hemodialysis. The nurse is working with the client to adapt the client's diet to maximize the therapeutic effect and minimize the risks of complications. The client's diet should include which of the following modifications? Select all that apply. a. Increased potassium intake b. Decreased protein intake c. Vitamin D supplementation d. Decreased sodium intake e. Fluid restriction
b. Decreased protein intake d. Decreased sodium intake e. Fluid restriction Restricting dietary protein decreases the accumulation of nitrogenous wastes, reduces uremic symptoms, and may even postpone the initiation of dialysis for a few months. Restriction of fluid is also part of the dietary prescription because fluid accumulation may occur. As well, sodium is usually restricted to 2 to 3 g/day. Potassium intake is usually limited, not increased, and there is no particular need for vitamin D supplementation.
A nurse is working with a client who has recently received a diagnosis of human immunodeficiency virus (HIV). When performing client education during discharge planning, what goal should the nurse prioritize? a. Appraise the client's level of nutritional awareness. b. Encourage the client to adhere to the client's therapeutic regimen. c. Encourage the client to exercise within the client's limitations. d. Encourage a disease-free state.
b. Encourage the client to adhere to the client's therapeutic regimen One of the goals of client education is to encourage people to adhere to the therapeutic regimen. This is a very important goal because it is necessary if clients are to attain their optimal level of wellness. In this client's circumstances, this is likely a priority over exercise or nutrition, though these are important considerations. A disease-free state is not obtainable.
The nurse is caring for a client who has developed SIADH. What intervention is most appropriate? a. Transfusion of fresh frozen plasma (FFP) b. Fluid restriction c. Transfusion of platelets d. Electrolyte restriction
b. Fluid restriction The nurse also assesses for complications of increased ICP, including diabetes insipidus, and SIADH. SIADH requires fluid restriction and monitoring of serum electrolyte levels. Transfusions are unnecessary.
The clinic nurse is doing a preoperative assessment of a client who will be undergoing outpatient cataract surgery with lens implantation in 1 week. While taking the client's medical history, the nurse notes that this client had a kidney transplant 8 years ago and that the client is taking immunosuppressive drugs. For what is this client at increased risk when having surgery? a. Rejection of the kidney b. Infection c. Adrenal storm d. Rejection of the implanted lens
b. Infection Because clients who are immunosuppressed are highly susceptible to infection, great care is taken to ensure strict asepsis. The client is unlikely to experience rejection or adrenal storm.
The nurse is creating a plan of care for a client who has a recent diagnosis of MS. Which of the following should the nurse include in the client's care plan? a. Encourage the client to void every hour. b. Instruct the client on daily muscle stretching. c. Order a low-residue diet. d. Provide total assistance with all ADLs.
b. Instruct the client on daily muscle stretching. A client diagnosed with MS should be encouraged to increase the fiber in his or her diet and void 30 minutes after drinking to help train the bladder. The client should participate in daily muscle stretching to help alleviate and relax muscle spasms.
The nurse is caring for a client at risk for an addisonian crisis. For what associated signs and symptoms should the nurse monitor the client? Select all that apply. a. Bounding pulse b. Rapid respiratory rate c. Epistaxis d. Hypotension e. Pallor
b. Rapid respiratory rate d. Hypotension e. Pallor The client at risk is monitored for signs and symptoms indicative of addisonian crisis, which can include shock; hypotension; rapid, weak pulse; rapid respiratory rate; pallor; and extreme weakness. Epistaxis and a bounding pulse are not symptoms or signs of an addisonian crisis.
A client with chronic obstructive pulmonary disease has recently begun a new bronchodilator. Which therapeutic effect(s) should the nurse expect from this medication? Select all that apply. a. Increased viscosity of lung secretions b. Relief of dyspnea c. Increased expiratory flow rate d. Increased respiratory rate e. Negative sputum culture
b. Relief of dyspnea c. Increased expiratory flow rate The relief of bronchospasm is confirmed by measuring improvement in expiratory flow rates and volumes (the force of expiration, how long it takes to exhale, and the amount of air exhaled) as well as by assessing the dyspnea and making sure that it has lessened. Increased respiratory rate and viscosity of secretions would suggest a worsening of the client's respiratory status. Bronchodilators would not have a direct result on the client's infectious process.
A client has been admitted to the postsurgical unit following a thyroidectomy. To promote comfort and safety, how should the nurse best position the client? a. Side-lying with one pillow under the head b. Semi-Fowler with the head supported on two pillows c. Head of the bed elevated 30 degrees and no pillows placed under the head d. Supine, with a small roll supporting the neck
b. Semi-Fowler with the head supported on two pillows When moving and turning the client, the nurse carefully supports the client's head and avoids tension on the sutures. The most comfortable position is the semi-Fowler position, with the head elevated and supported by pillows.
A nurse is assessing a client with HIV who has been admitted with pneumonia. In assessing the client, which of the following observations takes immediate priority? a. Frequent loose stools b. Tachypnea and restlessness c. Weight loss of 0.45 kg (1 lb) since yesterday d. Oral temperature of 37.2°C (99°F)
b. Tachypnea and restlessness In prioritizing care, tachypnea and restlessness are symptoms of altered respiratory status and need immediate priority. Weight loss of 1 lb is probably fluid related; frequent loose stools would not take short-term precedence over a temperature or tachypnea and restlessness. An oral temperature of 37.2°C (99°F) is not considered a fever and would not be the first issue addressed.
A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for: a. pleural effusion. b. atelectasis. c. pulmonary edema. d. oxygen toxicity.
b. atelectasis In a client with COPD, an ineffective cough impedes secretion removal. This, in turn, causes mucus plugging, which leads to localized airway obstruction — a known cause of atelectasis. An ineffective cough doesn't cause pleural effusion (fluid accumulation in the pleural space). Pulmonary edema usually results from left-sided heart failure, not an ineffective cough. Although many noncardiac conditions may cause pulmonary edema, an ineffective cough isn't one of them. Oxygen toxicity results from prolonged administration of high oxygen concentrations, not an ineffective cough.
The nurse is caring for a client who has returned to the postsurgical suite after postanesthetic recovery from a nephrectomy. The nurse's most recent assessment reveals increased sedation, shortness of breath, hypotension, and low urine output over the last 2 hours. What is the nurse's best response? a. Perform a full neurological assessment and notify the primary care provider. b. Increase the frequency of taking vital signs, monitor urine output, and notify the provider. c. Assess the client for signs of bleeding and inform the primary provider. d. Palpate the client's torso bilaterally for flank pain and notify the primary care provider.
c. Assess the client for signs of bleeding and inform the primary provider. Bleeding is a major complication of kidney surgery, and if missed can lead to hypovolemic (decreased volume of circulating blood) and hemorrhagic shock. Bleeding can be suspected when the client experiences fatigue, shortness of breath, and urine output of less than 400 mL within 24 hours. The postoperative client is monitored closely and these findings should be reported to the primary care provider. Ruling out the complication of the life-threatening condition of bleeding is the priority decision for this client. Performing a full neurological assessment will be warranted after the priority complications of surgery are ruled out. Increasing the monitoring of vital signs and urine output are just small parts of assessing the client for bleeding. Palpating the client's torso for flank pain may increase the client's pain and does not (in itself) address the most common cause of the client's signs and symptoms.
The nurse on the medical-surgical unit is reviewing discharge instructions with a client who has a history of glaucoma. The nurse should anticipate the use of what medications? a. Loop diuretics b. Potassium-sparing diuretics c. Cholinergics d. Antibiotics
c. Cholinergics Cholinergics are used in the treatment of glaucoma. The action of this medication is to increase aqueous fluid outflow by contracting the ciliary muscle and causing miosis and opening the trabecular meshwork. Diuretics and antibiotics are not used in the management of glaucoma.
A client newly diagnosed with hypertension asks the nurse what happens when uncontrolled hypertension is prolonged. The nurse explains that a client with prolonged, uncontrolled hypertension is at risk for developing which health problem? a. Anemia b. Right ventricular hypertrophy c. Chronic kidney disease d. Glaucoma
c. Chronic kidney disease When uncontrolled hypertension is prolonged, it can result in chronic kidney disease, myocardial infarction, stroke, impaired vision, left ventricular hypertrophy, and cardiac failure. Glaucoma and anemia are not directly associated with hypertension.
A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? a. Assessment of blood pressure and assessment for headaches and visual changes b. Assessments for signs and symptoms of venous thromboembolism c. Daily weights and abdominal girth measurement d. Blood glucose monitoring q4h
c. Daily weights and abdominal girth measurement Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.
An admitting nurse is assessing a client with COPD. The nurse auscultates diminished breath sounds, which signify changes in the airway. These findings indicate to the nurse to monitor the client for what? a. Sepsis and pneumothorax b. Bradypnea and pursed lip breathing c. Dyspnea and hypoxemia d. Kyphosis and clubbing of the fingers
c. Dyspnea and hypoxemia These changes in the airway require that the nurse monitor the patient for dyspnea and hypoxemia. Kyphosis is a musculoskeletal problem. Sepsis and pneumothorax are atypical complications. Tachypnea is much more likely than bradypnea. Pursed lip breathing can relieve dyspnea.
A client newly diagnosed with cancer is scheduled to begin chemotherapy treatment and the nurse is providing anticipatory guidance about potential adverse effects. When addressing the most common adverse effect, what should the nurse describe? a. Confusion b. Pruritis (itching) c. Nausea and vomiting d. Altered glucose metabolism
c. Nausea and vomiting Nausea and vomiting, the most common side effects of chemotherapy, may persist for as long as 24 to 48 hours after its administration. Antiemetic drugs are frequently prescribed for these clients. Confusion, alterations in glucose metabolism, and pruritus are less common adverse effects.
A nurse is teaching a client with asthma about the proper use of the prescribed inhaled corticosteroid. Which adverse effect should the nurse be sure to address in client teaching? a. Decreased level of consciousness b. Increased respiratory secretions c. Oral Candidiasis d. Bradycardia
c. Oral Candidiasis Thrush or oral candidiasis is a fungal infection that presents with white lesions on the tongue and/or inner cheeks of the mouth. Clients should rinse their mouth after administration or use a spacer to prevent thrush, a common complication associated with use of inhaled corticosteroids. Increased respiratory secretions normally do not occur, although a cough may develop. Tachycardia, or a fast heart rate, rather than bradycardia, or a slow heart rate, is listed as an adverse effect. A decreased level of consciousness is not associated with this medication because it does not cause sedation nor is it an opiate.
A client with Parkinson disease is undergoing a swallowing assessment because the client has recently developed adventitious lung sounds. The client's nutritional needs should be met by what method? a. Minced foods and a fluid restriction b. Total parenteral nutrition (TPN) c. Semisolid food with thick liquids d. Provision of a low-residue diet
c. Semisolid food with thick liquids A semisolid diet with thick liquids is easier for a client with swallowing difficulties to consume than is a solid diet. Low-residue foods and fluid restriction are unnecessary and counterproductive to the client's nutritional status. The client's status does not warrant TPN until all other options have been ruled out.
After having transurethral resection of the prostate (TURP), a client returns to the unit with a three-way indwelling urinary catheter and continuous closed bladder irrigation. Which finding suggests that the client's catheter is occluded? a. The normal saline irrigant is infusing at a rate of 50 drops/minute. b. The urine in the drainage bag appears red to pink. c. The client reports bladder spasms and the urge to void. d. About 1,000 ml of irrigant have been instilled; 1,200 ml of drainage have been returned.
c. The client reports bladder spasms and the urge to void. Reports of bladder spasms and the urge to void suggest that a blood clot may be occluding the catheter. After TURP, urine normally appears red to pink, and normal saline irrigant usually is infused at a rate of 40 to 60 drops/minute or according to facility protocol. The amount of returned fluid (1,200 ml) should correspond to the amount of instilled fluid, plus the client's urine output (1,000 ml + 200 ml), which reflects catheter patency.
A client with type 1 diabetes has told the nurse that the client's most recent urine test for ketones was positive. What is the nurse's most plausible conclusion based on this assessment finding? a. The client would benefit from a dose of metformin. b. The client should withhold the next scheduled dose of insulin. c. The client's insulin levels are inadequate. d. The client should promptly eat some protein and carbohydrates.
c. The client's insulin levels are inadequate. Ketones in the urine signal that there is a deficiency of insulin and that control of type 1 diabetes is deteriorating. Withholding insulin or eating food would exacerbate the client's ketonuria. Metformin will not cause short-term resolution of hyperglycemia.
A client has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The client's current medication regimen includes lactulose four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? a. Absence of nausea and vomiting b. Absence of blood or mucus in stool c. Two to three soft bowel movements daily d. Significant increase in appetite and food intake
c. Two to three soft bowel movements daily Lactulose is given to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the client's appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.
A nurse is teaching an educational class to a group of older adults at a community center. In an effort to prevent osteoporosis, the nurse should encourage participants to ensure that they consume the recommended intake of what nutrients? Select all that apply. a. Potassium b. Calcitonin c. Vitamin D d. Calcium e. Vitamin B12
c. Vitamin D d. Calcium A diet rich in calcium and vitamin D protects against skeletal demineralization. Intake of vitamin B12 and potassium does not directly influence the risk for osteoporosis. Calcitonin is not considered to be a dietary nutrient.
A client has been diagnosed with glaucoma and the nurse is preparing health education regarding the client's medication regimen. The client states that eagerness to "beat this disease" and looks forward to the time that the client will no longer require medication. How should the nurse best respond? a. "Most people are treated until their intraocular pressure goes below 50 mm Hg." b. "You have a great attitude. This will likely shorten the amount of time that you need medications." c. "You can likely expect a minimum of 6 months of treatment." d. "In fact, glaucoma usually requires lifelong treatment with medications."
d. "In fact, glaucoma usually requires lifelong treatment with medications." Glaucoma requires lifelong pharmacologic treatment. Normal intraocular pressure is between 10 and 21 mm Hg.
??A nurse is caring for a client with type 1 diabetes. The client's medication administration record includes the administration of regular insulin three times daily. Knowing that the client's lunch tray will arrive at 11:45 AM, when should the nurse administer the client's insulin? a. 11:45 AM b. 11:50 AM c. 10:45 AM d. 11:30 AM
d. 11:30 AM Short-acting insulin is called regular insulin. It is in a clear solution and is usually given 15 minutes before a meal or in combination with a longer-acting insulin. Earlier administration creates a risk for hypoglycemia; later administration creates a risk for hyperglycemia.
A patient is recovering in the hospital following a total hip replacement that was performed 2 days ago. In an effort to prevent the common complications associated with the surgical procedure, the nurse should implement which of the following interventions, as ordered? a. Passive range-of-motion (ROM) exercises with the affected leg b. Provision of a low-fiber, high-calorie diet c. Intermittent urinary catheterization to prevent urinary retention d. Application of sequential compression devices
d. Application of sequential compression devices The risk of venous thromboembolism is particularly great after reconstructive hip surgery. The nurse encourages the patient to consume adequate amounts of fluids, to perform ankle and foot exercises hourly while awake, and to use elastic stockings and sequential compression devices as prescribed. Passive ROM is not performed due to the high risk of injury. A low-fiber diet is not indicated, and intermittent catheterization is not used as a preventative measure.
The nurse is caring for a client who has developed dumping syndrome while recovering from a gastrectomy. What recommendation should the nurse make to the client? a. Choose foods that are high in simple carbohydrates. b. Sit upright when eating and for 30 minutes afterward. c. Drink a minimum of 12 ounces of fluid with each meal. d. Eat several small meals daily spaced at equal intervals.
d. Eat several small meals daily spaced at equal intervals. The client with dumping syndrome should consume small meals at intervals to reduce symptoms. The client should not consume fluids with meals. Carbohydrates should be limited and sitting upright does not relieve the symptoms.
A nurse is performing a shift assessment on an elderly client who is recovering after surgery for a hip fracture. The client reports chest pain, has an increased heart rate, and increased respiratory rate. The nurse further notes that the client is febrile and hypoxic, coughing, and producing large amounts of thick, white sputum. The nurse recognizes that this is a medical emergency and calls for assistance, recognizing that this client is likely demonstrating symptoms of what complication? a. Complex regional pain syndrome b. Compartment syndrome c. Avascular necrosis of bone d. Fat embolism syndrome
d. Fat embolism syndrome Fat embolism syndrome occurs most frequently in young adults and elderly clients who experience fractures of the proximal femur (i.e., hip fracture). Presenting features of fat embolism syndrome include hypoxia, tachypnea, tachycardia, and pyrexia. The respiratory distress response includes tachypnea, dyspnea, wheezes, precordial chest pain, cough, large amounts of thick, white sputum, and tachycardia. Avascular necrosis (AVN) occurs when the bone loses its blood supply and dies. This does not cause coughing. Complex regional pain syndrome does not have cardiopulmonary involvement.
A nurse is participating in the emergency care of a client who has just developed variceal bleeding. What intervention should the nurse anticipate? a. STAT administration of vitamin K by the intramuscular route b. IV administration of albumin c. Infusion of intravenous heparin d. IV administration of octreotide
d. IV administration of octreotide Octreotide—a synthetic analog of the hormone somatostatin—is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin. Because of this safety and efficacy profile, octreotide is considered the preferred treatment regimen for immediate control of variceal bleeding. Vitamin K and albumin are not given, and heparin would exacerbate, not alleviate, bleeding.
A client with end-stage renal disease receives continuous ambulatory peritoneal dialysis. The nurse observes that the dialysate drainage fluid is cloudy. What is the nurse's most appropriate action? a. Administer a bolus of IV normal saline as prescribed. b. Remove the catheter promptly and have the catheter tip cultured. c. Flush the peritoneal catheter with normal saline. d. Inform the health care provider and assess the client for signs of infection.
d. Inform the health care provider and assess the client for signs of infection. Peritonitis is the most common and serious complication of peritoneal dialysis. The first sign of peritonitis is cloudy dialysate drainage fluid, so prompt reporting to the primary provider and rapid assessment for other signs of infection are warranted. Administration of an IV bolus is not necessary or appropriate and the health care provider would determine whether removal of the catheter is required. Flushing the catheter does not address the risk for infection.
Diagnostic imaging and physical assessment have revealed that a client with peptic ulcer disease has suffered a perforated ulcer. The nurse recognizes that emergency interventions must be performed as soon as possible in order to prevent the development of what complication? a. Gastroesophageal reflux b. Acute pancreatitis c. Gastritis d. Peritonitis
d. Peritonitis Perforation is the erosion of the ulcer through the gastric serosa into the peritoneal cavity without warning. Chemical peritonitis develops within a few hours of perforation and is followed by bacterial peritonitis. Gastritis, reflux, and pancreatitis are not acute complications of a perforated ulcer.
A client's blood work reveals a platelet level of 17,000/mm3. When inspecting the client's integumentary system, what finding would be most consistent with this platelet level? a. Urticaria b. Dermatitis c. Alopecia d. Petechiae
d. Petechiae When the platelet count drops to less than 20,000/mm3, petechiae can appear. Low platelet levels do not normally result in dermatitis, urticaria (hives), or alopecia (hair loss).
The nurse is developing a plan of care for a client with Guillain-Barré syndrome. Which of the following interventions should the nurse prioritize for this client? a. Maintaining the client on bed rest b. Assessing frequently for loss of cognitive function c. Providing aids to compensate for loss of vision d. Using the incentive spirometer as prescribed
d. Using the incentive spirometer as prescribed Respiratory function can be maximized with incentive spirometry and chest physiotherapy. Nursing interventions toward enhancing physical mobility should be utilized. Nursing interventions are aimed at preventing a deep vein thrombosis. Guillain-Barré syndrome does not affect cognitive function or vision.
The nurse is caring for an older adult with a diagnosis of hypertension who is being treated with a diuretic and beta-blocker. Which item should the nurse integrate into the management of this client's hypertension? a. Carefully assess for weight loss because of impaired kidney function resulting from normal aging. b. Ensure that the client receives a larger initial dose of antihypertensive medication due to impaired absorption. c. Recognize that an older adult is less likely to adhere to the medication regimen than a younger client. d. Pay close attention to hydration status because of increased sensitivity to extracellular volume depletion.
d. pay close attention to hydration status because of increased sensitivity to extracellular volume depletion. Older adults have impaired cardiovascular reflexes and thus are more sensitive to extracellular volume depletion caused by diuretics. The nurse needs to assess hydration status, low BP, and postural hypotension carefully. Older adults may have impaired absorption, but they do not need a higher initial dose of an antihypertensive than a younger person. Adherence to treatment is not necessarily linked to age. Kidney function and absorption decline with age; less, rather than more antihypertensive medication is prescribed. Weight gain is not necessarily indicative of kidney function decline.
