PN2 NCLEX Style Questions Exam 3

•During the early postoperative period, a client who has undergone a cataract extraction complains of nausea and severe eye pain over the operative site. What should be the initial nursing action? •1. Call the surgeon •2. Reassure the client that this is normal •3. Turn the client onto her or his operative side •4. Administer the prescribed pain medication and antiemetic

1 Severe pain or pain accompanied by nausea following a cataract extraction is an indicator of increased intraocular pressure and should be reported to the surgeon immediately

The client sustains a contusion of the eyeball following a traumatic injury with a blunt object. Which intervention should be initiated immediately? 1. apply ice to the affected eye 2. irrigate the eye with cool water 3. Notify the primary health care provider 4. Accompany the client to the ER

1 Treatment for a contusion begins at the time of injury. Ice is applied immediately. The client then should be seen by a PCP and receive a thorough eye exam to rule out the presence of other eye injuries.

A client arrives in the ER with a penetrating eye injury from wood chips that occurred while cutting wood. The nurse assesses the eye and notes a piece of wood protruding from the eye. What is the initial nursing action? 1. apply an eye patch 2. perform visual acuity tests 3. irrigate the eye with sterile saline 4. Remove the piece of wood using a sterile eye clamp

2 If the eye injury is the result of a penetrating object, the object may be noted protruding from the eye. This object must never be removed except by the ophthalmologist, because it may be holding ocular structures in place. Application of an eye patch or irrigation of the eye may disrupt the foreign body and cause further tearing of the cornea.

A client is diagnosed with a problem involving the inner ear. Which is the most common client complaint associated with a problem involving this part of the ear? 1. pruritus 2. Tinnitus 3. Hearing loss 4. Burning in the ear

2 Tinnitus is the most common complaint of clients with ontological problems, especially problems involving the inner ear. Symptoms of tinnitus range from mild ringing in the ear, which can interfere with the client's thinking process and attention span

The nurse is developing a teaching plan for a client with glaucoma. Which instruction should the nurse include in the plan of care? 1. Avoid overuse of the eyes 2. Decrease the amount of salt in the diet 3. Eye medications will need to be administered for life 4. Decrease fluid intake to control the intraocular pressure

3 The administration of eye drops is a critical component of the treatment plan for the client with glaucoma. The client needs to be instructed that medications will need to be taken for the rest of their lives

The nurse is performing an admission assessment on a client with a diagnosis of detached retina. Which sign or symptom is associated with this eye problem? 1. total loss of vision 2. pain in the affected eye 3. a yellow discoloration of the sclera 4. a sense of curtain falling across the field of vision

4 A characteristic manifestation of retinal detachment described by the client is the feeling that a shadow or curtain is falling across the field of vision. No pain is associated with detachment of the retina. Is an ophthalmic emergency, and even more so if visual acuity is still normal.

The nurse is performing an assessment on a client with a suspected diagnosis of cataract. Which clinical manifestation should the nurse expect to note in the early stages of cataract formation? .1 Diplopia 2. Eye pain 3. Floating spots 4. Blurred vision

4 A gradual, painless blurring of central vision is the chief clinical manifestation of a cataract. Early symptoms include slightly blurred vision and a decrease in color perceptions

The nurse is performing an otoscopic exam on a client with mastoiditis. On exam of the tympanic membrane, which finding should the nurse expect to observe? 1. a pink-colored tympanic membrane 2. a pearly colored tympanic membrane 3. a transparent and clear tympanic membrane 4. a red, dull, thick, and immobile tympanic membrane

4 Otoscopic exam in a client with mastoiditis reveals a red, dull, thick, and immobile tympanic membrane, with or without perforation. Postauricular lymph nodes are tender and enlarged. Clients also have a low- grade fever, malaise, anorexia, swelling behind the ear, and pain

A client is prescribed prednisone for treatment of a type I reaction. The nurse plans to monitor the client for which adverse effects? Select all that apply. A. Fluid retention B. Gastric distress C. Hypotension D. Infection E. Osteoporosis

A. Fluid retention B. Gastric distress D. Infection E. Osteoporosis Rationale Hypertension is an adverse effect of prednisone.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? 1. Endotracheal intubation 2. 100 units of NPH insulin 3. Intravenous infusion of normal saline 4. Intravenous infusion of sodium bicarbonate

Answer 3: The primary goal of treatment in hyperosmolar hyperglycemic syndrome (HHS) js to rehydrate the client to restore fluid volume and to correct electrolyte deficiency. Intravenous (IV) fluid replacement is similar to that administered in diabetic ketoacidosis (DKA) and begins with IV infusion of normal saline. Regular insulin, not NPH insulin, would be administered. The use of sodium bicarbonate to correct acidosis is avoided because it can precipitate a further drop in serum potassium levels. Intubation and mechanical ventilation are not required to treat HHS

The nurse is teaching the client about his prescribed prednisone. Which statement, if made by the client, indicates that further teaching is necessary? 1. "l can take aspirin or my antihistamine if I need it." 2. "l need to take the medication every day at the same time." 3. "1 need to avoid coffee, tea, cola, and chocolate in my diet." 4. "If I gain more than 5 pounds (2.25 kg) a week, I will call my health care provider (HCP)."

Answer: 1 Rationale: Aspirin and other over-the-counter medications should not be taken unless the client consults with the HCP. The client needs to take the medication at the same time every day and should be instructed not to stop the medication. A slight weight gain as a result of an improved appetite is expected; however, after the dosage is stabilized, a weight gain of 5 pounds (2.25 kg) or more weekly should be reported to the HCP.

Which of the following findings should the nurse report to the client's physician for a client with unstable type 1 diabetes mellitus? Select all that apply. 1. Systolic blood pressure, 145 mm Hg. 2. Diastolic blood pressure, 87 mm Hg. 3. High-density lipoprotein (HDL), 30 mg/dL. 4. Glycosylated hemoglobin (HbAIC 10.2%. 5. Triglycerides, 425 mg/dL.

Answer: 1, 2, 3, 4, 5. The client with unstable diabetes mellitus is at risk for many microvascular and macrovascular complications. Heart disease is the leading cause of mortality in clients with diabetes. The goal blood pressure for diabetics is less than 130/80 mm Hg. Therefore, the nurse would need to report any findings greater than 130/80 mm Hg. The goal ofHbA1c is less than 7%; thus, a level of 10.2% must be reported. HDL less than 40 mg/dL and triglycerides greater than 150 mg/dL are risk factors for heart disease. The nurse would need to report the client's HDL and triglyceride levels. The urine ketones are negative, but this is a late sign of complications when there is a profound insulin deficiency.

A nurse is participating in a diabetes screening program. Who of the following is (are) at risk for developing type 2 diabetes? Select ail that apply. 1. A 32-year-old female who delivered a 9-lb infant. 2. A 44-year-old Native American Indian who has a body mass index (BMI) of 32. 3. An 18-year-old Hispanic who jogs four times a week. 4. A 55-year-old Asian American who has hypertension and two siblings with type 2 diabetes. 5. A 12-year-oid who is overweight.

Answer: 1, 2, 4, 5

A patient with newly diagnosed diabetes has peripheral neuropathy. Which key points should the nurse include in the teaching plan for this patient? Select all that apply. 1. "Clean and inspect your feet every day." 2. "Be sure that your shoes fit properly." 3. "Nylon socks are best to prevent friction on your toes from shoes.' 4. "Only a podiatrist should trim your toenails." 5. "Report any nonhealing skin breaks to your health care provider (HCP)." 6. "Use a thermometer to check the temperature of water before taking a bath"

Answer: 1, 2, 5, and 6: Sensory alterations are the major cause of foot complications inpatient with diabetes, and patients should be taught to examine their feet on a daily basis. Properly fitted shoes protect the patient from foot complications. Broken skin increases the risk of infection. Cotton socks are recommended to absorb moisture. Using a bath thermometer can prevent burn injuries. Patients, family, or HCP may trim toenails.

The nurse is preparing a teaching plan for a patient with type 2 diabetes who has been prescribed albiglutide. Which key points would the nurse include? Select all that apply. 1. The drug works in the intestine in response to food intake and acts with insulin for glucose regulation. 2. This drug increases cellular utilization of glucose, which lowers blood glucose levels. 3. This drug is used with diet and exercise to improve glycemic control in adults with type 2 diabetes. 4. The drug is an oral insulin that should be given only when the patient has something to eat immediately available. 5. Albigutide is administered by the subcutaneous route once a week.az

Answer: 1, 3, and 5: Albiglutide is an incretin mimetic. These drugs work like the natural "gut" hormones, glucagon-like peptide-I (GLP-I) and glucose- dependent isulinotropic polypeptide (GIP), that are released by the intestine in response to food intake and act with insulin for glucose regulation. They are used in addition to diet and exercise to improve glycemic control in adults with type 2 diabetes. Albiglutide is administered subcutaneously once a week.

Which information should the nurse include when developing a teaching plan for a client newly diagnosed with type 2 diabetes mellitus. Select all that apply. 1. A major risk factor for complications is obesity and central abdominal obesity. 2. Supplemental insulin is mandatory for controlling the disease. 3. Exercise increases insulin resistance. 4. The primary nutritional source requiring monitoring in the diet is carbohydrates. 5. Annual eye and foot examinations are recommended by the American Diabetes Association (ADA).

Answer: 1, 5. Being overweight and having a large waist-hip ratio (central abdominal obesity) increase insulin resistance, making control of diabetes more difficult. The ADA recommends a yearly referral to an ophthalmologist and podiatrist. Exercise and weight management decrease insulin resistance. Insulin is not always needed for type 2 diabetes; diet, exercise, and oral medications are the first-line treatment. The client must monitor all nutritional sources for a balanced diet-fats, carbohydrates, and protein.

A client with type 1 diabetes mellitus has influenza. The nurse should instruct the client to: 1. Increase the frequency of self-monitoring (blood glucose testing). 2. Reduce food intake to diminish nausea. 3. Discontinue that dose of insulin if unable to eat. 4. Take half of the normal dose of insulin.

Answer: 1. Colds and influenza present special challenges to the client with diabetes mellitus because the body's need for insulin increases during illness. Therefore, the client must take the prescribed insulin dose, increase the frequency of blood glucose testing, and maintain an adequate fluid intake to counteract the dehydrating effect of hyperglycemia. Clear fluids, juices, and Gatorade are encouraged. Not taking insulin when sick, or taking half the nonnal dose, may cause the client to develop ketoacidosis.

Which of the following is a priority nursing diagnosis for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza? 1. Imbalanced nutrition: Less than body requirements. 2. Ineffective health maintenance related to ineffective coping skills. 3. Acute pain. 4. Activity intolerance.

Answer: 1. Imbalanced nutrition: Less than body requirements is a priority nursing diagnosis for the client with diabetes mellitus who is experiencing vomiting with influenza. The diabetic client should eat small, frequent meals of 50 g of carbohydrate or food equal to 200 calories every 3 to 4 hours. If the client cannot eat the carbohydrates or take fluids, the health care provider should be called or the client should go to the emergency department. The diabetic client is in danger of complications with dehydration, electrolyte imbalance, and ketoacidosis. Increasing the client's coping skills is important to lifestyle behaviors, but it is not a priority during this acute illness of influenza. Pain relief may be a need for this client, but it is not the priority at this time; neither is intolerance for activity.

A client with diabetes is taking insulin lispro (Humalog) injections. The nurse should advise the client to eat: 1. Within 10 to 15 minutes after the injection. 2. 1 hour after the injection. 3. At any time, because timing of meals with lispro injections is unnecessary. 4. 2 hours before the injection.

Answer: 1. Insulin lispro (Humalog) begins to act within 10 to 15 minutes and lasts approximately 4 hours. A major advantage of Humalog is that the client can eat almost immediately after the insulin is administered. The client needs to be instructed regarding the onset, peak, and duration of all insulin, as meals need to be timed with these parameters. Waiting 1 hour to eat may precipitate hypoglycemia. Eating 2 hours before the insulin lispro could cause hyperglycemia if the client does not have circulating insulin to metabolize the carbohydrate.

The RN is orienting a new graduate nurse who is providing diabetes education for a patient about insulin injection. For which teaching statement by the new nurse must the RN intervene? 1. "To prevent lipohypertrophy, be sure to rotate injection sites from the abdomen to the thighs." 2. To correctly inject insulin, lightly grasp a fold of skin and inject at a 90-degree angle." 3. "Always draw your regular insulin into the syringe first before your NPH (neutral protamine Hagedorn) insulin." 4. "Avoid injecting the insulin into scarred sites because those areas slow the absorption rate of insulin."

Answer: 1: Although it is important to rotate injection sites for insulin, it is preferred that the injection sites be rotated within one anatomic site (e.g., the abdomen) to prevent day —to-day changes in the absorption rate of the insulin. All of the other teaching points are appropriate.

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? 1. "l need to stop my insulin" 2. "I need to increase my fluid intake" 3. "I need to monitor my blood glucose every 3 to 4 hours." 4. "I need to call the health care provider (HCP) because of these symptoms."

Answer: 1: When a client with diabetes mellitus is unable to eat normally because of illness, the client still should take the prescribed insulin or oral medication. The client should consume additional fluids and should notify the HCP. The client monitor the blood glucose level every 3 to 4 hours. The client should also monitor the urine for ketones during illness.

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? 1. Warm the client. 2. Maintain a patent airway. 3. Administer thyroid hormone. 4. Administer fluid replacement.

Answer: 2 Rationale: Myxedema coma is a rare but serious disorder that results from persistently low thyroid production. Coma can be precipitated by acute illness, rapid withdrawal of thyroid medication, anesthesia and surgery, hypothennia, and the use of sedatives and opioid analgesics. In myxedema coma, the initial nursing action is to maintain a patent airway. Oxygen should be administered, followed by fluid replacement, keeping the client warm, monitoring vital signs, and administering thyroid hormones by the intravenous route.

Gimepiride is prescribed for a client with diabetes mellitus. The nurse instructs the client that which food items are most acceptable to consume while taking this medication? Select all that apply. 1. Alcohol 2. Red meats 3. Whole-grain cereals 4. Low-calorie desserts 5. Carbonated beverages

Answer: 2, 3, 5 Rationale: When alcohol is combined with glimepiride, a disulfiramlike reaction may occur. This syndrome includes flushing, palpitations, and nausea. Alcohol can also potentiate the hypoglycemic effects of the medication. Clients need to be instructed to avoid alcohol consumption while taking this medication. Lowcalorie desserts should also be avoided. Even though the calorie content may be low, carbohydrate content is most likely high and can affect the blood glucose. The items in options 2, 3, and 5 are acceptable to consume.

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? Select all that apply. 1. Polyuria 2. Shakiness 3. Palpitations 4. Blurred vision 5. Lightheadedness 6. Fruity breath odor

Answer: 2, 3, and 5: Shakiness, palpitations, and lightheadedness are signs/symptoms of hypoglycemia and would indicate the need for food or glucose. Polyuria, blurred vision, and fruity breath odor are manifestations of hyperglycemia.

The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes? 1. Aspirin. 2. Steroids. 3. Sulfonylureas. 4. Angiotensin-converting enzyme (ACE) inhibitors.

Answer: 2. Steroids can cause hyperglycemia because of their effects on carbohydrate metabolism, making diabetic control more difficult. Aspirin is not known to affect glucose metabolism. Sulfonylureas are oral hypoglycemic agents used in the treatment of diabetes mellitus. ACE inhibitors are not known to affect glucose metabolism.

While the RN is performing an admission assessment on a patient with type 2 diabetes, the patient states that he routinely drinks 3 beer a day. What is the nurse's priority follow-up question at this time? 1. "Do you have any days when you do not drink?" 2. "When during the day do you drink your beers?" 3. "Do you drink any other forms of alcohol?" 4. "Have you ever had a lipid profile completed?"

Answer: 2: Alcohol has the potential for causing alcohol-induced hypoglycemia. It is important to know when the patient drinks alcohol and to teach the patient to ingest it shortly after meals to prevent this complication. The other questions are important but not urgent. The lipid profile question is important because alcohol can raise plasma triglycerides but is not as urgent as the potential for hypoglycemia.

A older patient with type 2 diabetes has cardiovascular autonomic neuropathy (CAN). Which instruction would the nurse provide for the unlicensed assistive personnel (UAP) assisting the patient with morning care? 1. Provide a complete bed bath for this patient. 2. Sit the patient up slowly on the side of the bed before standing. 3. Only let the patient wash his or her face and brush his or her teeth. 4. Be sure to provide rest periods between activities.

Answer: 2: CAN affects sympathetic and parasympathetic nerves of the heart and blood vessels. It may lead to orthostatic (postural) hypotension and syncope (brief loss of consciousness on standing) caused by failure of the heart and arteries to respond to position changes by increasing heart rate and vascular tone. The nurse should be sure to instruct the UAP to have the patient change positions slowly when moving from lying to sitting to standing.

A patient with diabetes has hot, dry skin; rapid and deep respirations; and a fruity odor to his breath. The charge nurse observes a newly graduated RN performing all the following patient tasks. Which action requires that the charge nurse intervene immediately? 1. Checking the patient's fingerstick glucose level 2. Encouraging the patient to drink orange juice 3. Checking the patient's order for sliding-scale insulin dosing Assessing the patient's vital signs every 15 minutes

Answer: 2: The signs and symptoms the patient is exhibiting are consistent with hyperglycemia. The RN should not give the patient additional glucose. All of the other interventions are appropriate for this patient. The RN should also notify the health care provider at this time.

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101 F (38.3t), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? 2. Respiration 3. Temperature 4. Blood pressure

Answer: 3 Rationale: In the client with type 2 diabetes mellitus, an elevated temperature may indicate infection. Infection is a leading cause of hyperosmolar hyperglycemic syndrome in the client with type 2 diabetes mellitus. The other findings are within normal limits

A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss? 1. Hypotension. 2. Decreased serum potassium level. 3. Rapid, deep respirations. 4. Warm, dry skin.

Answer: 3. Due to the rapid, deep respirations, the client is losing fluid from vaporization from the lungs and skin (insensible fluid loss). Normally, about 900 mL of fluid is lost per day through vaporization.

A client with type 1 diabetes is admitted to the emergency department with dehydration following the flu. The client has a blood glucose level of 325 mg/dL and a serum potassium level of 3.5 mEq. The physician has ordered 1,000 rnL 5% dextrose in water to be infused every 8 hours. Prior to implementing the physician orders, the nurse should contact the physician, explain the situation, provide background information, report the current assessment of the client, and: 1. Suggest adding potassium to the fluids. 2. Request an increase in the volume of intravenous fluids. 3. Verify the order for 5% dextrose in water. 4. Determine if the client should be placed in isolation.

Answer: 3. The client needs fluid volume replacement due to the dehydration. However, the nurse should verify the order for LV. dextrose with the physician due to the risk of hyperglycemia that dextrose would present when administered to a client with diabetes. The potassium level is within normal limits. The client does not have restrictions on oral fluids and the nurse can encourage the client to drink fluids. The client does not need to be placed in isolation at this time.

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? 1. An ampule of 50% dextrose 2. NPH insulin subcutaneously 3. IV fluids containing dextrose 4. Phenytoin for the prevention of seizures

Answer: 3: Emergency management of DKA focuses on correcting fluid and electrolyte imbalances and normalizing the serum glucose level. If the corrections occur too quickly, serious consequences, including hypoglycemia and cerebral edema, can occur. During management of DKA, when the blood glucose level falls to 250 to 300 mg/dL (14.2 to 17.1 mmoI/L), the IV infusion rate is reduced and a dextrose solution is added to maintain a blood glucose level of BOUT 250MG/Dl (14.2MMOL/l), or until the client recovers from ketosis. Fifty percent dextrose is used to treat hypoglycemia. NPH insulin is not used to treat DKA. Phenytoin is not usual treatment measure for DKA.

The patient with type 2 diabetes has a health care provider prescription for NPO status for a cardiac catheterization. An LPN/LVN who is assigned to administer medications to this patient asks the supervising RN whether the patient should receive his ordered repaglinide, What is the RN's best response? 1. "Yes, because this drug will increase the patient's insulin secretion and prevent hyperglycemia." 2. "No, because this drug may cause the patient to experience gastrointestinal symptoms such as nausea." 3. "No, because this drug should be given 1 to 30 minutes before meals and the patient is NPO." 4. "Yes, because this drug should be taken three times day whether the patient eats or not."

Answer: 3: Repaglinide is a meglitinide analog drug. These drugs are short-acting agents used to prevent postmeal blood glucose elevation. They should be given within 1 hour to 30 minutes before meals and cause hypoglycemia shortly after dosing when meal is delayed or omitted.

A client is to receive glargine (Lantus) insulin in addition to a dose of aspart (NovoLog). When the nurse checks the blood glucose level at the bedside, it is greater than 200 mg/ dL. How should the nurse administer the insulins? 1. Put air into the glargine insulin vial, and then air into the aspart insulin vial, and draw up the correct dose of aspart insulin first. 2. Roll the glargine insulin vial, then roll the aspart insulin vial. Draw up the longer-acting glargine insulin first. 3. Shake both vials of insulin before drawing up each dose in separate insulin syringes. 4. Put air into the glargine insulin vial, and draw up the correct dose in an insulin syringe; then, with a different insulin syringe, put air into the aspart via' and draw up the correct dose.

Answer: 4. Glargine (Lantus) is a long-acting recombinant human insulin analog. Glargine should not be mixed with any other insulin product. Insulins should not be shaken; instead, if the insulin is cloudy, roll the vial or insulin pen between the palms of the hands.

During a home visit, a diabetic client begins to cry and says, Il l just cannot stand the thought of having to give myself a shot every day." Which of the following would be the best response by the nurse? 1. "If you do not give yourself your insulin shots, you will die." 2. "We can teach your daughter to give the shots so you will not have to do it." 3. "l can arrange to have a home care nurse give you the shots every day." 4. "What is it about giving yourself the insulin shots that bothers you?"

Answer: 4. The best response is to allow the client to verbalize her fears about giving herself a shot each day. Tactics that increase fear are not effective in changing behavior. If possible, the client needs to be responsible for her own care, including giving self-injections. It is unlikely that the client's insurance company will pay for home-care visits if the client is capable of self-administration.

The client with type 1 diabetes mellitus is taught to take isophane insulin suspension NPH (Humulin N) at 5 p.m. each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time? 1. 11 a.m., shortly before lunch. 2. 1 p.m., shortly after lunch. 3. 6 p.m., shortly after dinner. 4. 1 a.m., while sleeping

Answer: 4. The client with diabetes mellitus who is taking NPH insulin (Humulin N) in the evening is most likely to become hypoglycemic shortly after midnight because this insulin peaks in 6 to 8 hours. The client should eat a bedtime snack to help prevent hypoglycemia while sleeping.

A patient has a newly-diagnosed type 2 diabetes. Which task should the RN delegate to an experienced unlicensed assistive personnel (UAP)? 1. Arranging a consult with the dietitian 2. Assessing the patient's insulin injection technique 3. Teaching the patient to use a glucometer to monitor glucose at home 4. Checking the patient's glucose level before each meal

Answer: 4: The experienced UAP would have been taught to perform tasks such as checking pulse oximetry and glucose checks, and these actions would be part of his or her scope of practice. Arranging for a consult with a dietitian is appropriate for the unit clerk. Teaching and assessing require additional education and should be carried out by licensed nurse.

The nurse is caring for an 81-year-old adult with type 2 diabetes, hypertension, and peripheral vascular disease. Which admission assessment findings increase the patient's risk for development of hyperglycemic-hyperosmolar syndrome (HHS)? Select all that apply. 1. Hydrochlorothiazide (HCTZ) prescribed to control her blood pressure 2. Weight gain of 6 lb. (2.7 kg) over the past month 3. Avoids consuming liquids in the evening 4. Blood pressure 168/94 mm Hg 5. Urine output of 50 to 75 mL/hr. 6. Glucose greater than 600mg/dL (33.3 mmol/L)

Answers: 1, 3, and 6: HHS often occurs in older adults with type 2 diabetes. Risk factors include taking diuretics and inadequate fluid intake. Serum glucose is greater than 600mg/dL (33.3 mmol/L). Weight loss (not weight gain) would be a symptom. Although the patient's blood pressure is high, this is not a risk factor. A urine output of 50 to 75 mL/hr. is adequate.

The RN is caring for a patient with diabetes admitted with hypoglycemia that occurred at home. Which teaching points for treatment of hypoglycemia at home would the nurse include in the teaching plan for the patient and family before discharge? Select all that apply. 1. Signs and symptoms of hypoglycemia include hunger, irritability, weakness, headache, and blood glucose less than 60mg/dL (3.3mmol/L). 2. Treat hypoglycemia with 4 to 8 g of carbohydrate such as glucose tablets or % cup (60 mL) of fruit juice. 3. Retest blood glucose in 30 minutes. 4. Repeat the carbohydrate treatment if the symptoms do not resolve. 5. Eat a small snack of carbohydrate and protein if the next meal is more than an hour away. 6. If the patient has serve hypoglycemia, does not respond to treatment, and is unconscious, transport to the emergency department (ED)

Answers: 1, 4, 5, and 6: The manifestations listed in option 1 are correct. The symptoms should be treated with carbohydrates, but 10 to 15 g (not 4-8g). Glucose should be retested at 15 minutes; 30 minutes is too long to wait. Options 4 and 5 are correct. When a patient has severe hypoglycemia, does not respond to administration of glucagon, and remains unconscious, he or she should be transported to the ED and the health care provider notified.

1) A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. 1. Increase in pH 2. Comatose state 3. Deep, rapid breathing 4. Decreased urine output 5. Elevated blood glucose level

Answers: 2, 3, and 5: Because of the profound deficiency of insulin associated with DKA, glucose cannot be used for energy and the body breaks down fat as a secondary source of energy. Ketones, which are acid byproducts of fat metabolism, build up and the client experiences a metabolic ketoacidosis. High serum glucose contributes to an osmotic diuresis and the client becomes severely dehydrated. If untreated, the client will become comatose due to severe dehydration, acidosis, and electrolyte imbalance. Kussmaul's respirations, the deep rapid breathing associated with DKA, is a compensatory mechanism by the body. The body attempts to correct the acidotic state by blowing off carbon dioxide, which is an acid. In the absence of insulin, the client will experience severe hyperglycemia. Option 1 is incorrect because in acidosis the pH would be low. Option 4 is incorrect because a high serum glucose will result in an osmotic diuresis and the client wilt experience polyuria.

After the first injection of an immunotherapy program, the nurse notices a large, red wheal on the client's arm, coughing, and expiratory wheezing. Which intervention should the nurse implement first? A. Notifying the health care provider immediately B. Administering I.M. epinephrine per protocol C. Beginning oxygen by way of nasal cannula D. Starting an I.V. line for medication administration

B. Administering I.M. epinephrine per protocol Immediately on noticing the client's sign and symptoms, the nurse would determine that the client is experiencing anaphylaxis to the injection. The first action is to give 0.2 to 0.5 ml of epinephrine I.M. Notifying the health care provider, beginning oxygen administration, and starting an I.V. line follow after the initial injection of epinephrine is administered.

Which intervention should the nurse discuss with a patient who has an allergic disorder and is requesting information for allergy symptom control? (Select all that apply.) A. Instructing the client to refrain from using air conditioning or humidifiers in the house B Instructing the client to use curtains instead of pull shades over windows C Instructing the client to cover the mattress with a hypoallergenic cover D Instructing the client to wear a mask when cleaning E Instructing the client to avoid using sprays, powders, and perfumes F Instructing the client to change detergents frequently

C,D,E Using hypoallergenic covers and cosmetics will help reduce the chance of n allergic attack, wearing mask while cleaning will help decrease the amount of dust entering the lungs, and avoiding sprays, powders, and perfumes will help decrease the chance of an allergic attack. The client should use air conditioning and humidifiers. Drapes, curtains, blinds, and carpets should be removed. The client should not change detergents or soaps

A patient has a deep puncture wound on his foot from stepping on a nail. When the nurse prepares to give him a tetanus toxoid vaccination, he says he does not need another tetanus shot because he had a tetanus shot just 1 year ago. What is the nurse's best response? A. "You need this vaccination because the strain of tetanus changes every year." B. "i will check with the doctor. You probably do not need another vaccination now." C. "Because antibody production slows down as you age, it is better to take this vaccination as a booster to the one you had a year ago." D. "Tetanus is a more serious disease among younger people because it can be spread to others by sexual transmission, so it is best to take this vaccination now."

C. "Because antibody production slows down as you age, it is better to take this vaccination as a booster to the one you had a year ago. "When people have been "boosting" their tetanus antibodies on a regularly scheduled basis, they should have sufficient circulating antibodies to mount a defense against exposure to tetanus. If this client's medical records substantiate that he did indeed receive a tetanus toxoid booster 1 year ago, he does not need another one now.

1. Which condition or health problem demonstrates inflammation without invasion? a. Allergic rhinitis b. Viral hepatitis c. Osteoarthritis d. Cellulitis e. None of above

C. Osteoarthritis Osteoarthritis is a "wear and tear" disorder that mechanically causes tissue damage. All the other disorders represent invasion by non-self proteins such as pollens, viruses, and bacteria

A patient is undergoing plasmapheresis for treatment of systemic lupus erythematosus. The nurse explains that plasmapheresis is used in her treatment to A. remove T lymphocytes in her blood that are producing anti-nuclear antibodies B. remove normal particles in her blood that are being damaged by autoantibodies. C. exchange her plasma that contains antinuclear antibodies with a substitute fluid. D. replace viral-damaged cellular components of her blood with replacement whole blood.

C. exchange her plasma that contains antinuclear antibodies with a substitute fluid. Exchange her plasma that contains antinuclear antibodies with a substitute fluid. Plasmapheresis is used to remove antibodies from the bloodstream, thereby preventing them from attacking their targets.

The client receives infliximab (Remicade), an immunosuppressant medication. What is the priority information for the nurse to teach the client about this medication? A. The client should get adequate exercise. B. The client should drink plenty of fluids. C. The client should eat plenty of fruits and vegetables. D. The client should avoid crowds.

D. The client should avoid crowds. Avoiding crowds is important to avoid exposure to infection.

A nurse has educated a client on an epinephrine auto-injector (EpiPen). What statement by the client indicates additional instruction is needed? a. "l don't need to go to the hospital after using it." b. "l must carry two EpiPens with me at all times." c. "l will write the expiration date on my calendar." d. "This can be injected right through my clothes

a. "l don't need to go to the hospital after using it." Clients should be instructed to call 911 and go to the hospital for monitoring after using the EpiPen. The other statements show good understanding of this treatment.

Why is the inflammatory response alone insufficient to provide complete protection against infection? a. It only responds to tissue injury and not to invasion by microorganisms. b. It is nonspecific and no long-lasting immunity is generated by inflammation alone. c. When the inflammatory response is prolonged, it can cause serious tissue damage. d. The body is not capable of synthesizing antibodies at the same time that inflammatory processes are active. e. None of above

b. It is nonspecific and no long-lasting immunity is generated by inflammation alone. The cells that provide the protection of inflammation, the neutrophils and the macrophages, have no "memory" to aid them in mounting a faster or stronger response to an invading microorganism upon repeated or subsequent exposure. Without antibody-mediated immunity and cell-mediated immunity to augment the inflammatory response, humans remain susceptible to reinfection by the same microorganism over and over again.

Which manifestations or processes of inflammation are caused specifically by blood vessel dilation ? a. Increased production and migration of leukocytes b. Phagocytosis and fever c. Warmth and redness d. Swelling and pain e. None of above

c. Warmth and redness Dilated blood vessels increase blood flow to an area, leading to increased warmth and color in that area. Dilation alone does not result in swelling. Swelling results from increased capillary permeability.

A women was working in her garden. She accidently sprayed insectide into her right eye. She calls the ER frantic and screaming for help. The nurse should instruct the woman to take which immediate action? 1. irrigate the eyes with water 2. come to the ER 3. call the PCP 4. irrigate the eyes with diluted hydrogen peroxide

•1 •In this type of accident, the client is instructed to irrigate the eye immediately with running water for at least 20min or until the emergency medical services personnel arrive. In the ER, the cleansing agent of choice is usually normal saline.

The nurse is preparing to test the visual acuity of a client, using a Snellen chart. Which identifies the accurate procedure for this visual acuity test? 1. the right eye is tested, followed by the left eye, and then both eyes are tested. 2. both eyes are assessed together, followed by an assessment of the right eye and then the left eye 3. the client is asked to stand at a distance of 40 feet from the chart and to read the largest line on the chart 4. the client is asked to stand at a distance of 40 feet from the chart and to read the line that can be read 200 feet away by an individual with unimpaired vision

•1 •Visual acuity is assessed in 1 eye at a time, and then in both eyes together, with the client comfortably standing or sitting. The right eye is tested with the left eye covered, then the lt eye is tested with the rt eye covered. Both eyes are then tested together. Visual acuity is measured with or without corrective lenses, and the client stands at a distance of 20ft from the chart

The nurse is preparing a teaching plan for a client who had a cataract extraction with intraocular implantation. Which home care measures should the nurse include in the plan? SATA 1. Avoid activities that require bending over 2. contact the surgeon if eye scratchiness occurs 3. Take acetaminophen for minor eye discomfort 4. expect episodes of sudden severe pain in the eye 5. plan an eye shield on the surgical eye at bedtime 6. contact the surgeon if a decrease in visual acuity occurs

•1, 3, 5, 6 •Following eye surgery, some scratchiness and mild eye discomfort may occur in the operative eye and usually is relieved by mild analgesics. If the eye pain becomes severe, the client should notify the surgeon, because this may indicate hemorrhage, infection, or increased intraocular pressure. The nurse also would instruct the client to notify the surgeon of increased purulent drainage, increased redness, or any decrease in visual acuity. The client is instructed to place an eye shield over the operative eye at bedtime to protect the eye from injury during sleep and to avoid activities that increase intraocular pressure, such as bending over

A client with Meniere's disease is experiencing severe vertigo. Which instruction should the nurse give to the client to assist in controlling the vertigo? 1. increase sodium in the diet 2. avoid sudden movements 3. lie still and watch TV 4. increase fluid intake to 3000mL a day

•2 •The nurse instructs the client to make slow head movements to prevent worsening of the vertigo. Dietary changes such as salt and fluid restrictions that reduce the amount of endolymphatic fluid are sometimes prescribed.

Tonometry is performed on a client with a suspected diagnosis of glaucoma. The nurse looks at the documented test results and notes an intraocular pressure value of 23. What should be the nurse's initial action? 1. apply normal saline drops 2. note the time of day the test was done 3. contact the primary health provider (PCP) 4. instruct the client to sleep with the head of bed flat

•2 •Tonometry is a method of measuring intraocular fluid pressure. Pressures between 10 and 21mm Hg are considered within normal range. However Intraocular pressure is slightly higher in the morning. The initial action is to check the time the test was performed. Normal saline drops are not a specific treatment for glaucoma.

A client's vision is tested with a Snellen chart. The results of the tests are documented as 20/60. What action should the nurse implement based on this finding? 1. provide the client with materials on legal blindness 2. instruct the client that he or she may need glasses when driving 3. inform the client of where her or she can purchase a white cane with a red tip 4. inform the client that it is best to sit near the back of the room when attending lectures

•2 •Vision at 20/20 is normal - the client is able to read form 20ft what a person with normal vision can read from 20ft. A client with a visual acuity of 20/60 can read at a distance of 20 ft what a person with normal vision can read at 60vt. Which this vision, the client should be instructd to sit in the front of the room for lectures to aid in visualization. This is not considered to be legal blindness

The nurse is caring for a hearing - impaired client. Which approach will facilitate communication? 1. speak loudly 2. speak frequently 3. speak at a normal volume 4. speak directly into the impaired ear

•3 • speaking in a normal tone to the client with the impaired hearing and not shouting are important. The nurse should talk directly to the client while facing the client and speak clearly. If the client does not seem to understand what it said, the nurse should express it differently. Moving closer to the client and toward the better ear may facilitate communication, but the nurse should avoid talking directly into the impaired ear.

The nurse is caring for a client following enucleation to treat an ocular tumor and notes the presence of bright red drainage on the dressing. Which action should the nurse take at this time? 1. Document the finding 2. Continue to monitor the drainage 3. Notify the primary health provider 4. Mark the drainage on the dressing and monitor for any increase in bleeding

•3 •If the nurse notes the presence of bright red drainage on the dressing, itmust be reported to the PCP, because this indicates hemorrhage

The nurse notes that the primary care provider has documented a diagnosis of presbycusis on a client's chart. Based on this information, what action should the nurse take? 1. speak loudly but mumble or slur the words 2. speak loudly and clearly while facing the client 3. speak at a normal tone and pitch, slowly and clearly 4. speak loudly and directly into the client's affected ear

•3 •Presbycusis is a type of hearing loss that occurs with aging. Presbycusis is a gradual sensorineural loss caused by nerve degeneration in the inner ear or auditory nerve. When communicating with a client with this condition, the nurse should speak at a normal tone and pitch, slowly and clearly. It is not appropriate to speak loudly, mumble or slur words, or speak into the client's affected ear.

The nurse is caring for a client following craniotomy for removal of an acoustic neuroma. Assessment of which cranial nerve would identify a complication specifically associated with this surgery? 1. cranial nerve I - olfactory 2. cranial nerve IV, trochlear 3. cranial nerve III, oculomotor 4. cranial nerve VII, facial nerve

•4 •An acoustic neuroma is a unilateral benign tumor that occurs where the vestibulocochlear or acoustic nerve - cranial nerve VIII- enters the internal auditory canal. It is important that any early diagnosis be made, because the tumor can compress the trigeminal and facial nerves and arteries within the internal auditory canal. Treatment is surgical removal via a craniotomy. Assessment of the trigeminal and facial nerves is important. Extreme care is taken to preserve remaining hearing and preserve the function of the facial nerve.