Rando question 4

165. During the transfer of a client who had major abdominal surgery this morning, the post anesthesia care unit (PACU) nurse reports that the client, who is awake and responsive continues to report pain and nausea after receiving morphine 2 mg IV and ondansetron 4 mg IV 45 mints ago. Which elements of SBAR communication are missing from the report given by the PACU nurse? (Select all that apply) ● Situation ● Background ● Assessment ● Recommendation ● Rationales.

v● Background ● Assessment ● Recommendation RATIONALE: BCD are correct. The current situation is reported regarding the client's nausea and pain (A). Based on SBAR communication, critical information about the client's clinical history (B), and assessment (C) such as pain scale or vital signs related to client's response to medication, are not included, nor are any recommendations for further follow-up (D). (E) Is not a component of SBAR communication

180. A male client with COPD smokes two packs of cigarettes per day and is admitted to the hospital for a respiratory infection. He complains that he has trouble controlling respiratory distress at home when using his rescue inhaler. Which comment from the client indicates to the nurse that he is not using his inhaler properly? ● "I have a hard time inhaling and holding my breath after I squeeze the inhaler, but I do my best" ● "I never use the inhaler unless I am feeling really short of breath" ● I always shake the inhaler several times before I start" ● "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away"

● "After I squeeze the inhaler and swallow, I always feel a slight wave of nausea, bit it goes away"

171. A nurse working on an endocrine unit should see which client first? ● An adolescent male with diabetes who is arguing about his insulin dose. ● An older client with Addison's disease whose current blood sugar level is 62mg/dl (3.44 mmol/l). ● An adult with a blood sugar of 384mg/dl (21.31mmol/l) and urine output of 350 ml in the last hour. ● A client taking corticosteroids who has become disoriented in the last two hours.

● A client taking corticosteroids who has become disoriented in the last two hours. RATIONALE: meeting the client's need for safety is a priority intervention. Mania and psychosis can occur during corticosteroids therapy, places the client at risk for injury, so the patient taking corticosteroids should be seen first.

185. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first? ● A client with congestive heart failure who reports a 3-pound weight gain in the last two days ● An immobile client with a stage 3 pressure ulcer on the coccyx who is having low back pain ● A client diagnosed with chronic obstructive pulmonary disease (COPD) who is short of breath ● A terminally ill older adult who has refused to eat or drink anything for the last 48 hours

● A client with congestive heart failure who reports a 3-pound weight gain in the last two days

182. When assessing a male client, the nurse notes that he has unequal lung expansion. What conclusion regarding this finding is most likely to be accurate? The client has ● A collapsed lung ● A history of COPD ● A chronic lung infection ● Normally functioning lungs

● A collapsed lung

184. A client is admitted with an exacerbation of heart failure secondary to COPD. Which observations by the nurse require immediate intervention to reduce the likelihood of harm to this client? (Select all that apply). ● A bedside commode is positioned near the bed ● A saline lock is present in the right forearm ● A full pitcher of water is on the bedside table ● The client is lying in a supine position in bed ● A low sodium diet tray was brought to the room

● A full pitcher of water is on the bedside table ● The client is lying in a supine position in bed

177. After several hours of non-productive coughing, a client presents to the emergency room complaining of chest tightness and shortness of breath. History includes end stage chronic obstructive pulmonary disease (COPD) and diabetes mellitus. While completing the pulmonary assessment, the nurse hears wheezing and poor air movement bilaterally. Which actions should the nurse implement? (Select all that apply.)

● Administer PRN nebulizer treatment. ● Obtain 12 lead electrocardiogram. ● Monitor continuous oxygen saturation.

178. In assessing an older female client with complication associated with chronic obstructive pulmonary disease (COPD), the nurse notices a change in the client's appearance. Her face appears tense and she begs the nurse not to leave her alone. Her pulse rate is 100, and respirations are 26 per min. What is the primary nursing diagnosis?

● Anxiety related to fear of suffocation.

157. The nurse is evaluating the diet teaching of a client with hypertension. What dinner selection indicates that the client understands the dietary recommendation for hypertension?

● Baked pork chop, applesauce, corn on the cob, 2% milk, and key-lime pie

190. An older male client with type 2 diabetes mellitus reports that has experiences legs pain when walking short distances, and that the pain is relieved by rest. Which client behavior indicates an understanding of healthcare teaching to promote more effective arterial circulation? ● Consistently applies TED hose before getting dressed in the morning. ● Frequently elevated legs thorough the day. ● Inspect the leg frequently for any irritation or skin breakdown ● Completely stop cigarette/ cigar smoking.

● Completely stop cigarette/ cigar smoking. RATIONALE: Stopping cigarette smoking helps to decrease vasoconstriction and improve arterial circulation to the extremity.

196. The nurse reviews the signs of hypoglycemia with the parents of a child with Type I diabetes mellitus. The parents correctly understand signs of hypoglycemia if they include which symptoms? ● Fruity breath odor ● Polyphagia ● Diaphoresis ● Polydipsia

● Diaphoresis

161. An infant who is admitted for surgical repair of a ventricular septal defect (VSD) is irritable and diaphoretic with jugular vein distention. Which prescription should the nurse administer first?

● Digoxin.

159. The nurse and an unlicensed assistive personnel (UAP) are providing care for a client with a nasogastric tube (NGT) when the client begins to vomit. How should the nurse manage this situation? ● Determine the presence of hematemesis as the UAP irrigates the NGT ● Instruct the UAP to bring an antiemetic to the nurse at the bedside ● Assess the appearance of the emesis while the UAP checks bowel sounds ● Direct the UAP to measure the emesis while the nurse irrigates the NGT

● Direct the UAP to measure the emesis while the nurse irrigates the NGT

187. The nurse is planning a class for a group of clients with diabetes mellitus about blood glucose monitoring. In teaching the class as a whole, the nurse should emphasize the need to check glucose levels in which situation?

● During acute illness

160. While a child is hospitalized with acute glomerulonephritis, the parents ask why blood pressure readings are taken so often. Which response by the nurse is most accurate? ● Blood pressure fluctuations means that the condition has become chronic ● Elevated blood pressure must be anticipated and identified quickly ● Hypotension leading to sudden shock can develop at any time ● Sodium intake with meals and snacks affects the blood pressure

● Elevated blood pressure must be anticipated and identified quickly

191. In preparing a diabetes education program, which goal should the nurse identify as the primary emphasis for a class on diabetes self-management? ● Prepare the client to independently treat their disease process ● Reduce healthcare costs related to diabetic complications ● Enable clients to become active participating in controlling the disease process ● Increase client's knowledge of the diabetic disease process and treatment options.

● Enable clients to become active participating in controlling the disease process RATIONALE: The primary goal of diabetic self- management education is to enable the client to become an active participant in the care and control of disease process, matching levels of self- management to the abilities of the individual client. The goal is to place the client in a cooperative or collaborative role with healthcare professional rather than (A)

162. Progressive kyphoscoliosis leading to respiratory distress is evident in a client with muscul...Which finding warrants immediate intervention by the nurse?

● Evidence of hypoventilation

198. The nurse is developing a plan of care for a middle-aged woman who is diagnosed with type 2 diabetes mellitus (DM). To lower her blood glucose and increase her serum high-density lipoprotein (HDL) levels, which instruction is most important for the nurse to provide? ● Exercise at least three times weekly ● Monitor blood glucose levels daily ● Limit intake of foods high in saturated fat ● Learn to read all food product labels

● Exercise at least three times weekly

176. When performing postural drainage on a client with Chronic Obstructive Pulmonary Disease (COPD), which approach should the nurse use?

● Explain that the client may be placed in five positions

189. When development a teaching plan for a client newly diagnosed type 1 diabetes, the nurse should explain that an increase thirst is an early sing of diabetes ketoacidosis (DKA), which action should the nurse instruct the client to implement if this sign of DKA occur? ● Resume normal physical activity ● Drink electrolyte fluid replacement ● Give a dose of regular insulin per sliding scale ● Measure urinary output over 24 hours.

● Give a dose of regular insulin per sliding scale . RATIONALE: As hyperglycemia persist, ketone body become a fuel source, and the client manifest early signs of DKA that include excessive thirst, frequent urination, headache, nausea and vomiting. Which result in dehydration and loss of electrolyte. The client should determine fingersticks glucose level and self-administer a dose of regular insulin per sliding scale.

173. A client with Addison's crisis is admitted for treatment with adrenal cortical supplementation. Based on the client's admitting diagnosis, which findings require immediate action by the nurse? (Select all that apply)

● Headache and tremors ● Postural hypotension ● Pallor and diaphoresis ● Irregular heartbeat

188. The healthcare provider prescribes acarbose (Precose), an alpha-glucosidase inhibitor, for a client with Type 2 diabetes mellitus. Which information provides the best indicator of the drug's effectiveness?

● Hemoglobin A1C (HbA1C) reading less than 7%

174. A client with Addison's disease becomes weak, confused, and dehydrated following the onset of an acute viral infection. The client's laboratory values include; sodium 129 mEq/l (129mmol/l SI), glucose 54 mg/dl (2.97mmol/l SI) and potassium 5.3 mmol/l SI). When reporting the findings to the HCP, the nurse anticipates a prescription for which intravenous medications? ● Regular insulin. ● Hydrocortisone ● Broad spectrum antibiotic ● Potassium chloride

● Hydrocortisone

152. A nurse is caring for a client with Diabetes Insipidus. Which assessment finding warrants immediate intervention by the nurse? ● Hypernatremia ● Excessive thirst ● Elevated heart rate ● Poor skin turgor

● Hypernatremia

163. Which action should the school nurse take first when conducting a screening for scoliosis?

● Inspect for symmetrical shoulder height.

164. The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement? ● Instruct the mother to change the child's diaper more often. ● Encourage the mother to apply lotion with each diaper charge ● Tell the mother to cleanse with soap and water at each diaper change ● Ask the mother to decrease the infant's intake of fruits for 24 hours.

● Instruct the mother to change the child's diaper more often.

172. Which medication should the nurse anticipate administering to a client who is diagnosed with myxedema coma? ● Intravenous administration of thyroid hormones ● Oral administration of hypnotic agents ● Intravenous bolus of hydrocortisone ● Subcutaneous administration of vitamin k

● Intravenous administration of thyroid hormones RATIONALE: The high mortality of myxedema coma requires immediate administration of IV thyroid hormones (A). (B) Is contraindicated, because eves small doses can cause profound somnolence lasting longer than expected. (C) Is administered to clients diagnosed with adrenal insufficiency (Addisonian crisis) and (D) to clients who have had an overdose of warfarin.

166. After placing a stethoscope as seen in the picture, the nurse auscultates S1 and S2 heart sounds. To determine if an S3 heart sound is present, what action should the nurse take first?

● Listen with the bell at the same location

200. The nurse is assessing a middle-aged adult who is diagnosed with osteoarthritis. Which factor in this client's history is a contributor to the osteoarthritis? ● Long distance runner since high school. ● Lactose intolerant since childhood ● Photosensitive to a drug currently taking ● Recently treated for deep vein thrombosis

● Long distance runner since high school.

192. A client with type 2 diabetes mellitus is admitted for antibiotic treatment for a leg ulcer. To monitor the client for the onset of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), what actions should the nurse take? (Select all that apply) ● Check urine for ketones ● Measure blood glucose ● Monitor vital signs ● Assessed level of consciousness ● Obtain culture of wound

● Measure blood glucose ● Monitor vital signs ● Assessed level of consciousness RATIONALE: Blood glucose greater than 600 mg/dl (33.3 mmol/L SI), vital sign changes in mental awareness are indicators of possible HHNS. Urine ketones are monitored in diabetic ketoacidosis. Wound culture is performed prior to treating the wound infection but is not useful in monitoring for HHNS.

169. A client with a history of cirrhosis and alcoholism is admitted with severe dyspnea and ascites. Which assessment finding warrants immediate intervention by the nurse? ● Jaundice skin tone ● Muffled heart sounds ● Pitting peripheral edema ● Bilateral scleral edema

● Muffled heart sounds RATIONALE: Muffled heart sounds may indicative fluid build-up in the pericardium and is life- threatening. The other one are signs of end stage liver disease related to alcoholism but are not immediately life- threatening.

167. The nurse is auscultating a client's heart sounds. Which description should the nurse use to document this sound? (Please listen to the audio first to select the option that applies)

● Murmur RATIONALE: A murmur is auscultated as a swishing sound that is associated with the blood turbulence created by the heart or valvular defect.

170. An older adult client with heart failure (HF) develops cardiac tamponade. The client has muffled, distant, heart sounds, and is anxious and restless. After initiating oxygen therapy and IV hydration, which intervention is most important for the nurse to implement? ● Observe neck for jugular vein distention ● Notify healthcare provider to prepare for pericardiocentesis ● Asses for paradoxical blood pressure ● Monitor oxygen saturation (Sp02) via continuous pulse oximetry

● Notify healthcare provider to prepare for pericardiocentesis RATIONALE: Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space between the heart muscle (myocardium) and the outer covering sac of the heart (pericardium). In this condition, blood or fluid collects in the pericardium, the sac surrounding the heart. This prevents the heart ventricles from expanding fully. The excess pressure from the fluid prevents the heart from working properly. As a result, the body does not get enough blood.

153. While removing an IV infusion from the hand of a client who has AIDS, the nurse is struck with the needle. After washing the puncture site with soap & water, which action should the nurse take?

● Notify the employee health nurse.

199. A client is admitted for type 2 diabetes mellitus (DM) and chronic Kidney disease (CKD, which breakfast selection by the client indicates effective learning?

● Oatmeal with butter, artificial sweetener, and strawberries, and 6 ounces coffee

193. The nurse is teaching a male adolescent recently diagnosed with type 1diabetes mellitus (DM) about self-injecting insulin. Which approach is best for the nurse to use to evaluate do you effectiveness of the teaching? ● Ask the adolescent to describe his level of comfort with injecting himself with insulin. ● Observe him as he demonstrates self-injection technique in another diabetic adolescent ● Have the adolescent list the procedural steps for safe insulin administration. ● Review his glycosylated hemoglobin level 3 months after the teaching session.

● Observe him as he demonstrates self-injection technique in another diabetic adolescent . RATIONALE: watching the adolescent perform the procedure with another adolescent provides peer support the most information regarding his skill with self-injection. Other options do not provide information about the effectiveness of nurse's teaching.

181. An older male who is admitted for end stage of chronic obstructive pulmonary disease (COPD) tells the nurse .... The client provides the nurse with a living will and DNR. What action should the nurse implement?

● Obtain a prescription for DNR

151. A client with possible acute kidney injury (AKI) is admitted to the hospital and mannitol is prescribed as a fluid challenge. Prior to carrying out this prescription, what intervention should the nurse implement? ● Collect a clean catch urine specimen. ● Instruct the client to empty the bladder. ● Obtain vital signs and breath sounds. ● No specific nursing action is required

● Obtain vital signs and breath sounds. RATIONALE: the client's baseline cardiovascular status should be determined before conducting the fluid challenge. If the client manifests changes in the vital signs and breath sounds associated with pulmonary edema, the administration of the fluid challenge should be terminate. Other options would not assure a safe administration of the medication.

158. An older adult resident of a long-term care facility has a 5-year history of hypertension. The client has a headache and rate the pain 5 on a pain scale 0 to 10. The client's blood pressure is currently 142/89. Which interventions should the nurse implement? (Select all that apply) ● Administer a daily dose of lisinopril as scheduled. ● Assess the client for postural hypotension. ● Notify the healthcare provider immediately ● Provide a PRN dose of acetaminophen for headache ● Withhold the next scheduled daily dose of warfarin.

● Provide a PRN dose of acetaminophen for headache ● Administer a daily dose of lisinopril as scheduled. RATIONALE: the client' routinely scheduled medication, lisinopril, is an antihypertensive medication and should be administered as scheduled to maintain the client's blood pressure. A PRN dose of acetaminophen should be given for the client's headache. The other options are not indicated for this situation.

186. A client who is newly diagnosed with type 2 diabetes mellitus (DM) receives a prescription for metformin (Glucophage) 500 mg PO twice daily. What information should the nurse include in this client's teaching plan? (Select all that apply.)

● Recognize signs and symptoms of hypoglycemia. ● Report persist polyuria to the healthcare provider. ● Take Glucophage with the morning and evening meal.

183. Which interventions should the nurse include in a long-term plan of care for a client with COPD? ● Reduce risk factors for infection ● Limit fluid intake to reduce secretions ● Use diaphragmatic breathing to achieve better exhalation ● Administer high flow oxygen during sleep

● Reduce risk factors for infection

175. Which intervention should the nurse include in a long-term plan of care for a client with Chronic Obstructive Pulmonary Disease (COPD)? ● Reduce risks factors for infection ● Administer high flow oxygen during sleep ● Limit fluid intake to reduce secretions ● Use diaphragmatic breathing to achieve better exhalation

● Reduce risks factors for infection

154. During shift report, the central electrocardiogram (EKG) monitoring system alarms. Which client alarm should the nurse investigate first?

● Respiratory apnea of 30 seconds

179. An older adult male is admitted with complications related to chronic obstructive pulmonary disease (COPD). He reports progressive dyspnea that worsens on exertion and his weakness has increased over the past month. The nurse notes that he has dependent edema in both lower legs. Based on these assessment findings, which dietary instruction should the nurse provide? ● Limit the intake of high calorie foods. ● Eat meals at the same time daily. ● Maintain a low protein diet. ● Restrict daily fluid intake.

● Restrict daily fluid intake. RATIONALE: the client is exhibiting signs of cor pulmonale, a complication of COPD that causes the right side of the heart to fail. Restricting fluid intake to 1000 to 2000 ml/day, eating a high-calorie diet at small frequent meals with foods that are high in protein and low in sodium can help relive the edema and decrease workload on the right-side of the heart.

194. An Insulin infusion for a client with diabetes mellitus who is experiencing hyperglycemic hyperosmolar...in addition to the client's glucose, which laboratory value is most important for the nurse to monitor? ● Serum potassium ● Urine ketones ● Urine albumin ● Serum protein

● Serum potassium

156. A male client with hypertension, who received new antihypertensive prescriptions at his last visit returns to the clinic two weeks later to evaluate his blood pressure (BP). His BP is 158/106 and he admits that he has not been taking the prescribed medication because the drugs make him "feel bad". In explaining the need for hypertension control, the nurse should stress that an elevated BP places the client at risk for which pathophysiological condition?

● Stroke secondary to hemorrhage

195. A client who is recently diagnosed with type 2 diabetes mellitus (DM) ask the nurse how this type of diabetes leads to high blood sugar. What Pathophysiology mechanism should the nurse explain about the occurrence of hyperglycemia in those who have type 2 DM?

● The body cells develop resistance to the action of insulin

155. The nurse is explaining the need to reduce salt intake to a client with primary hypertension. What explanation should the nurse provide? ● High salt can damage the lining of the blood vessels ● Too much salt can cause the kidneys to retain fluid ● Excessive salt can cause blood vessels to constrict ● Salt can cause information inside the blood vessels

● Too much salt can cause the kidneys to retain fluid RATIONALE: Excessive salt intake can contribute to primary hypertension by causing renal salt retention which influence water retention that expands blood volume and pressure (ACD) are not believed to contribute to primary hypertension.

197. A client with gestational diabetes is undergoing a non-stress test (NST) at 34-week gestation... is 144 beats/minute. The client is instructed to mark the fetal monitor by pressing a button each time the baby moves. After 20 minutes, the nurse evaluates the fetal monitor strip. What...

● Two FHR accelerations of 15 beats/minute x 15 seconds are recorded