Adult final exam Nclex questions

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which of the following findings would the nurse expect to note as confirming this diagnosis? 1. Elevated blood glucose and low plasma bicarbonate 2. Decreased urine output 3. Increased respirations and an increase in pH 4. Coma

1

Which client complaint would alert the nurse to a possible hypoglycemic reaction? 1. Tremors 2. Anorexia 3. Hot, dry skin 4. Muscle cramps

1

nurse reinforces teaching with a client with diabetes mellitus regarding differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that glucose will be taken if which symptom develops? 1. Polyuria 2. Shakiness 3. Blurred vision 4. Fruity breath odor

2

The nurse caring for a client who has had a subtotal thyroidectomy reviews the plan of care and determines which problem is the priority for this client in the immediate postoperative period? 1. Dehydration 2. Infection 3. Urinary retention 4. Bleeding

4

When the nurse is teaching a client who has been newly diagnosed with type 1 diabetes mellitus, which statement by the client would indicate that teaching has been effective? 1. "I will stop taking my insulin if I'm too sick to eat." 2. "I will decrease my insulin dose during times of illness." 3. "I will adjust my insulin dose according to the level of glucose in my urine." 4. "I will notify my health care provider if my blood glucose level is greater than 250 mg/dL."

4

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs more teaching? A. "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." B. "I need to take good care of my belly and ankle skin where it is swollen." C. "A scrotal support may be more comfortable when I have scrotal edema." D. "I can use pillows to support my head to help me breathe when I am in bed."

A

Nurse Oliver should expect a client with hypothyroidism to report which health concerns? a. Increased appetite and weight loss b. Puffiness of the face and hands c. Nervousness and tremors d. Thyroid gland swelling

B

Which assessment information will be most important for the nurse to report to the health care provider about a patient with acute cholecystitis? a. The patient's urine is bright yellow. b. The patient's stools are tan colored. c. The patient has increased pain after eating. d. The patient complains of chronic heartburn.

B

A female client with hypothyroidism (myxedema) is receiving levothyroxine (Synthroid), 25 mcg P.O. daily. Which finding should nurse Hans recognize as an adverse drug effect? a. Dysuria b. Leg cramps c. Tachycardia d. Blurred vision

C

n the administration of a drug such as levothyroxine (Synthroid), the nurse should teach the client: A) That therapy typically lasts about 6 months. B) That weekly laboratory tests for T4 levels will be required. C) To report weight loss, anxiety, insomnia, and palpitations. D) That the drug may be taken every other day if diarrhea occurs.

C

Causes of primary hypothyroidism in adults include a. malignant or benign thyroid nodules b. surgical removal or failure of the pituitary gland c. surgical removal or radiation of thyroid gland d. autoimmune-induced atrophy of the gland

D

Which assessment finding is of most concern for a 46-year-old woman with acute pancreatitis? a. Absent bowel sounds b. Abdominal tenderness c. Left upper quadrant pain d. Palpable abdominal mass

D

Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a. Increased serum albumin level b. Decreased indirect bilirubin level c. Improved alertness and orientation d. Fewer episodes of bleeding varices

D

A client is admitted to the hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial serum glucose level was 950 mg/dL. Intravenous (IV) insulin was started along with rehydration with IV normal saline. The serum glucose level is now 240 mg/dL. The nurse who is assisting in caring for the client obtains which of the following items, anticipating a health care provider's prescription 1. IV infusion containing 5% dextrose 2. NPH insulin and a syringe for subcutaneous injection 3. An ampule of 50% dextrose 4. Phenytoin (Dilantin) for prevention of seizures

1

A client with diabetes mellitus is being discharged following treatment for hyperglycemic hyperosmolar nonketotic syndrome (HHNS) precipitated by acute illness. The client states to the nurse, "I will call the doctor next time I can't eat for more than a day or so." The nurse plans care, understanding that which of the following accurately reflects this client's level of knowledge? 1. The client needs immediate education before discharge. 2. The client's statement is accurate, but knowledge should be evaluated further. 3. The client's statement is inaccurate, and the client should be scheduled for outpatient diabetic counseling. 4. The client requires follow-up teaching regarding the administration of insulin.

1

A nurse has reinforced home care measures to a client diagnosed with diabetes mellitus regarding exercise and insulin administration. Which statement by the client indicates a need for further instruction? 1. "I should perform my exercise at peak insulin time." 2. "I should always carry a quick-acting carbohydrate when I exercise." 3. "I should always wear a Medic-Alert bracelet especially when I exercise." 4. "I should avoid exercising at times when a hypoglycemic reaction is likely to occur."

1

A nurse is assigned to assist in caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the priority nursing action is to plan to prepare to: 1. Administer intravenous (IV) regular insulin. 2. Administer IV 5% dextrose. 3. Correct the acidosis. 4. Apply an electrocardiogram (ECG) monitor.

1

A nurse is assigned to care for a client at home who has a diagnosis of type 1 diabetes mellitus. When the nurse arrives to care for the client, the client tells the nurse that she has been vomiting and has diarrhea. Which additional statement by the client indicates a need for further teaching? 1. "I need to stop my insulin." 2. "I need to increase my fluid intake." 3. "I need to call my health care provider." 4. "I need to monitor my blood glucose every 4 to 6 hours."

1

A nurse is assisting in preparing a care plan for a client with diabetes mellitus who has hyperglycemia. The nurse focuses on which potential problem for this client? 1. Dehydration 2. The need for knowledge about the causes of hyperglycemia 3. Lack of knowledge about nutrition 4. Inability of family to cope with the client's diagnosis

1

A nurse is collecting data from a client newly diagnosed with diabetes mellitus regarding the client's learning readiness. Which client behavior indicates to the nurse that the client is not ready to learn? 1. The client complains of fatigue whenever the nurse plans a teaching session. 2. The client asks if the spouse can attend the classes also. 3. The client asks for written materials about diabetes before class. 4. The client asks appropriate questions about what will be taught.

1

A nurse is collecting data on a client with a diagnosis of hypothyroidism. Which of these behaviors, if present in the client's history, would the nurse determine as being likely related to the manifestations of this disorder? 1. Depression 2. Nervousness 3. Irritability 4. Anxiety

1

A nurse is monitoring a client following a thyroidectomy for signs of hypocalcemia. Which of the following signs, if noted in the client, likely indicates the presence of hypocalcemia? 1. Tingling around the mouth 2. Negative Chvostek's sign 3. Flaccid paralysis 4. Bradycardia

1

A nurse is monitoring a client who has been newly diagnosed with diabetes mellitus for signs of complications. Which of the following, if exhibited by the client, would indicate hyperglycemia and thus warrant health care provider notification?1. Polyuria 2. Bradycardia 3. Diaphoresis 4. Hypertension

1

A nurse is reinforcing dietary instructions to a client newly diagnosed with diabetes mellitus. The nurse instructs the client that it is best to: 1. Eat meals at approximately the same time each day. 2. Adjust mealtimes depending on blood glucose levels. 3. Vary mealtimes if insulin is not administered at the same time every day. 4. Avoid being concerned about the time of meals as long as snacks are taken on time.

1

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. The appropriate intervention to decrease the client's anxiety would be to: 1. Administer a sedative. 2. Convey empathy, trust, and respect toward the client. 3. Ignore the signs and symptoms of anxiety so that they will soon disappear. 4. Make sure the client knows all the correct medical terms so that he or she can understand what is happening.

2

A client with type 1 diabetes mellitus takes NPH insulin every morning and checks the blood glucose level four times per day. The client tells the nurse that yesterday the late afternoon blood glucose was 60 mg/dL and that she "felt funny." Which statement by the client would indicate an understanding of this occurrence? 1. "My blood glucose levels are running low because I'm tired." 2. "I forgot to take my usual afternoon snack yesterday." 3. "I took less insulin this morning so I won't feel funny today." 4. "I don't know why I have to check my blood glucose four times a day. That seems too much."

2

A nurse has reinforced instructions about measuring blood glucose levels to a client newly diagnosed with diabetes mellitus. The nurse determines that the client understands the procedure when making which most accurate statement? 1. "I should check my blood glucose level before eating a big meal." 2. "I should check my blood glucose level before eating each meal, regardless of how much I eat." 3. "I should check my blood glucose level 2 hours after each meal." 4. "I should check my blood glucose level once a day."

2

A nurse is collecting data on a client admitted to the hospital with a diagnosis of myxedema. Which data collection technique will provide data necessary to support the admitting diagnosis? 1. Auscultation of lung sounds 2. Inspection of facial features 3. Percussion of the thyroid gland 4. Palpation of the adrenal glands

2

What would the nurse anticipate being included in the plan of care for a client who has been diagnosed with Graves' disease? 1. Provide a high-fiber diet. 2. Provide a restful environment. 3. Provide three small meals per day. 4. Provide the client with extra blankets.

2

Which of the following clients is at risk for developing thyrotoxicosis? 1. A client with hypothyroidism 2. A client with Graves' disease who is having surgery 3. A client with diabetes mellitus scheduled for debridement of a foot ulcer 4. A client with diabetes insipidus scheduled for an invasive diagnostic test

2

A nurse is caring for a client with hypothyroidism who is overweight. Which food items would the nurse suggest to include in the plan? 1. Peanut butter, avocado, and red meat 2. Skim milk, apples, whole-grain bread, and cereal 3. Organ meat, carrots, and skim milk 4. Seafood, spinach, and cream cheese

2`

A client is brought to the emergency department with suspected diabetic ketoacidosis (DKA). Which of the following findings would the nurse note as being consistent with this diagnosis?

3

A client with diabetes mellitus calls the clinic nurse to report that the blood glucose level is 150 mg/dL. After obtaining further data from the client, the nurse determines that the client ate lunch approximately 2 hours ago. The nurse would interpret these results to be: 1. Normal 2. Lower than the normal value 3. Slightly higher than the normal value 4. A value that indicates immediate health care provider notification

3

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions to the client regarding the program. Which of the following should the nurse include in the teaching plan? 1. Try to exercise before mealtime. 2. Administer insulin after exercising. 3. Take a blood glucose test before exercising. 4. Exercise should be performed during peak times of insulin.

3

A nurse in an outpatient diabetes clinic is assisting in caring for a client on insulin pump therapy. Which statement by the client indicates that a knowledge deficit exists regarding insulin pump therapy? 1. "If my blood sugars are elevated, I can bolus myself with additional insulin as prescribed." 2. "I'll need to check my blood sugars before meals in case I need a pre-meal insulin bolus." 3. "Now that I have this pump, I don't have to worry about insulin reactions or ketoacidosis occurring again." 4. "I still need to follow an appropriate diet and exercise plan even though I don't have to inject myself daily anymore."

3

A nurse is assisting in preparing a plan of care for the client with diabetes mellitus and plans to reinforce the client's understanding regarding the symptoms of hypoglycemia. Which symptoms will the nurse review? 1. Slow pulse; lethargy; and warm, dry skin 2. Elevated pulse; lethargy; and warm, dry skin 3. Elevated pulse; shakiness; and cool, clammy skin 4. Slow pulse, confusion, and increased urine output

3

A nurse is caring for a client newly diagnosed with diabetes mellitus. The client asks the nurse whether eating at a restaurant will affect the diabetic control and whether this is allowed. Which nursing response is appropriate? 1. "You really should not eat in restaurants." 2. "If you plan to eat in a restaurant, you need to avoid carbohydrates." 3. "You should order a half-portion meal and have fresh fruit for dessert." 4. "You should increase your daily dose of insulin by half on the day you plan to eat out."

3

A nurse is preparing to administer an injection of regular insulin. The vial of the regular insulin has been refrigerated. On inspection of the vial, the nurse finds that the medication is frozen. The nurse should: 1. Wait for the insulin to thaw at room temperature. 2. Check the temperature settings of the refrigerator. 3. Discard the insulin and obtain another vial. 4. Rotate the vial between the hands until the medication becomes liquid.

3

A nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which of the following specific signs of this complication should be included on the list? 1. Decreased urine output 2. Profuse sweating 3. Increased thirst 4. Shakiness

3

A nurse is reinforcing instructions with a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) regarding measures to prevent a recurrence. Which instruction is important for the nurse to emphasize? 1. Eat six small meals daily. 2. Test the urine ketone levels. 3. Monitor blood glucose levels frequently. 4. Receive appropriate follow-up health care.

3

A nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement, if made by the client, indicates the need for further teaching? 1. "I'll eat a balanced meal plan." 2. "I need to drink diet soft drinks." 3. "I need to buy special dietetic foods." 4. "I will snack on fruit instead of cake."

3

A client who is managing diabetes mellitus with insulin injections asks the nurse for information about any necessary changes in her diet to avoid hyperinsulinism. Which of the following diets would be appropriate for the client? 1. Low-fiber, high-fat diet 2. Limit carbohydrate intake to three meals per day 3. Large amounts of carbohydrates between low protein meals 4. Small frequent meals with protein, fat, and carbohydrates at each meal

4

A client with Graves' disease has exophthalmos and is experiencing photophobia. Which intervention would best assist the client with this problem? 1. Administering methimazole (Tapazole) every 8 hours 2. Lubricating the eyes with tap water every 2 to 4 hours 3. Instructing the client to avoid straining or heavy lifting 4. Obtaining dark glasses for the client

4

A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the nurse that after giving the injection, the insulin seems to leak through the skin. The nurse can appropriately determine the problem by asking the client which of the following? 1. "Are you placing an air bubble in the syringe before injection?" 2. "Are you using a 1-inch needle to give the injection?" 3. "Are you aspirating before you inject the insulin?" 4. "Are you rotating the injection site?"

4

A hospitalized client is newly diagnosed with diabetes mellitus. The client must take both NPH and Regular insulin for glucose control. The nurse develops a teaching plan to help the client meet which outcome as a first step in managing the disease? 1. Avoid all strenuous exercise. 2. Maintain health at an optimum level. 3. Lose 40 pounds to achieve ideal body weight. 4. Adjust insulin according to capillary blood glucose levels. rationale

4

A nurse enters the room of a client with type 1 diabetes mellitus and finds the client difficult to arouse. The client's skin is warm and flushed, and the pulse and respiratory rate are elevated from the client's baseline. The nurse would immediately: 1. Prepare for the administration of an insulin drip. 2. Give the client a glass of orange juice. 3. Prepare for the administration of a bolus dose of 50% dextrose. 4. Check the client's capillary blood glucose.

4

A nurse has collected data on a client with diabetes mellitus. Findings include a fasting blood glucose of 130 mg/dL, temperature 101° F, pulse of 88 beats per minute, respirations of 22 breaths per minute, and a blood pressure of 118/78 mm Hg. Which finding would be of concern to the nurse? 1. Pulse and respirations 2. Blood pressure 3. Blood glucose 4. Temperature

4

A nurse is caring for a client experiencing thyroid storm. Which of the following would be a priority concern for this client? 1. Inability to cope with the treatment plan 2. Lack of sexual drive 3. Self-consciousness about body appearance 4. Potential for cardiac disturbances

4

A nurse is caring for a client following a thyroidectomy. The client tells the nurse that she is concerned because of voice hoarseness. The client asks the nurse whether the hoarseness will subside. The nurse appropriately tells the client that the hoarseness: 1. Indicates nerve damage 2. Is harmless but permanent 3. Will worsen before it subsides 4. Is normal and will gradually subside

4

A nurse is collecting data from a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the medication regimen? 1. "I should take my metformin (Glucophage) only if my blood glucose is elevated." 2. "By taking these medications, I am able to eat more." 3. "When I become ill, I need to increase the number of pills I take." 4. "The medication that I am taking helps release the insulin I already make."

4

A nurse is preparing a diet plan for a 50yr with simple goiter. Which of the following should be included in the clients diet to decrease the enlargement of the thyroid gland? a. iodine b. sodium c. potassium d. calcium

A

A patient has sought care because of a loss of 25 lb over the past 6 months, during which the patient claims to have made no significant dietary changes. What potential problem should the nurse assess the patient for? A. Thyroid disorders B. Diabetes insipidus C. Pituitary dysfunction D. Parathyroid dysfunction

A

After thyroidectomy, which of the following is the priority assessment to observe laryngeal nerve damage? a) hoarseness of voice b) difficulty in swallowing c) tetany d) fever

A

The nurse is planning care for a 48-year-old woman with acute severe pancreatitis. The highest priority patient outcome is a. maintaining normal respiratory function. b. expressing satisfaction with pain control. c. developing no ongoing pancreatic disease. d. having adequate fluid and electrolyte balance.

A

13. A 53-year-old patient is being treated for bleeding esophageal varices with balloon tamponade. Which nursing action will be included in the plan of care? a. Instruct the patient to cough every hour. b. Monitor the patient for shortness of breath. c. Verify the position of the balloon every 4 hours. d. Deflate the gastric balloon if the patient reports nausea.

B

A nurse is completing preoperative teaching for a client who will undergo a laparoscopic cholecystectomy. Which of the following should be included in the teaching? A. "The scope will be passed through your rectum." B. "You may have shoulder pain after surgery." C. "The T-tube will remain in place for 1 to 2 weeks." D. "You should limit how often you walk for 1 to 2 weeks."

B

A patient with hypothyroidism is treated with Synthroid. When teaching the patient about the therapy, the nurse a. explains that caloric intake must be reduced when drug therapy is started b. provides written instruction for all information related to the medication therapy c. assures the patient that a return to normal function will occur with replacement therapy d. informs the patient that medications must be taken until hormone balance is reestablished

B

Early this morning, a female client had a subtotal thyroidectomy. During evening rounds, nurse Tina assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs? a. Diabetic ketoacidosis b. Thyroid crisis c. Hypoglycemia d. Tetany

B

For a patient with cirrhosis, which of the following nursing actions can the registered nurse (RN) delegate to unlicensed assistive personnel (UAP)? a. Assessing the patient for jaundice b. Providing oral hygiene after a meal c. Palpating the abdomen for distention d. Assisting the patient to choose the diet

B

Of what precautions should a client receiving radioactive iodine-131 be made aware? a.) Drink plenty of fluids, especially those high in calcium. b.) Avoid close contact with children or pregnant women for one week after administration of drug. c.) Be aware of the symptoms of tachycardia, increased metabolic rate, and anxiety. d.) Wear a mask if around children or pregnant women

B

The nurse is caring for a 55-year-old man patient with acute pancreatitis resulting from gallstones. Which clinical manifestation would the nurse expect the patient to exhibit? A. Hematochezia B. Left upper abdominal pain C. Ascites and peripheral edema D. Temperature over 102o F (38.9o C)

B

The nurse is caring for a 73-year-old man who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? a. The patient complains of right upper-quadrant pain with palpation. b. The patient's hands flap back and forth when the arms are extended. c. The patient has ascites and a 2-kg weight gain from the previous day. d. The patient's skin has multiple spider-shaped blood vessels on the abdomen.

B

The nurse recognizes that teaching a 44-year-old woman following a laparoscopic cholecystectomy has been effective when the patient states which of the following? a. "I can expect yellow-green drainage from the incision for a few days." b. "I can remove the bandages on my incisions tomorrow and take a shower." c. "I should plan to limit my activities and not return to work for 4 to 6 weeks." d. "I will always need to maintain a low-fat diet since I no longer have a gallbladder."

B

The patient with right upper quadrant abdominal pain has an abdominal ultrasound that reveals cholelithiasis. What should the nurse expect to do for this patient? A. Prevent all oral intake. B. Control abdominal pain. C. Provide enteral feedings. D. Avoid dietary cholesterol.

B

The patient with sudden pain in the left upper quadrant radiating to the back and vomiting was diagnosed with acute pancreatitis. What intervention(s) should the nurse expect to include in the patient's plan of care? A. Immediately start enteral feeding to prevent malnutrition. B. Insert an NG and maintain NPO status to allow pancreas to rest. C. Initiate early prophylactic antibiotic therapy to prevent infection. D. Administer acetaminophen (Tylenol) every 4 hours for pain relief.

B

Which goal has the highest priority in the plan of care for a 26-year-old homeless patient admitted with viral hepatitis who has severe anorexia and fatigue? a. Increase activity level. b. Maintain adequate nutrition. c. Establish a stable environment. d. Identify sources of hepatitis exposure.

B

Which nursing action is most appropriate for a client in ketoacidosis? a. admin of carbs b. admin of IV fluids c. applying cold compress d. giving glucagon IV

B

Which of the following assessment findings characterize thyroid storm? a) increased body temperature, decreased pulse, and increased blood pressure b) increased body temperature, increased pulse, and increased blood pressure c) increased body temperature, decreased pulse, and decreased blood pressure d) increased body temperature, increased pulse, and decreased blood pressure

B

4. A nurse is reviewing the health record of a client who has pancreatitis. The physical exam report by the provider indicates the presence of Cullen's sign. Which of the following is an appropriate action by the nurse to identify this finding? A. Tap lightly at the costovertebral margin on the client's back. B. Palpate the client's right lower quadrant. C. Inspect the skin around the umbilicus. D. Auscultate the area below the client's scapula.

C

A nursing student is studying for a test on care of the client with endocrine disorders. Which of the following statements demonstrates an understanding of the difference between hyperthyroidism and hypothyroidism? a. "Deficient amounts of TH cause abnormalities in lipid metabolism, with decreased serum cholesterol and triglyceride levels." b. "Graves' disease is the most common cause of hypothyroidism." c. "Decreased renal blood flow and glomerular filtration rate reduces the kidney's ability to excrete water, which may cause hyponatremia." d. "Increased amounts of TH cause a decrease in cardiac output and peripheral blood flow."

C

An incoherent female client with a history of hypothyroidism is brought to the emergency department by the rescue squad. Physical and laboratory findings reveal hypothermia, hypoventilation, respiratory acidosis, bradycardia, hypotension, and nonpitting edema of the face and pretibial area. Knowing that these findings suggest severe hypothyroidism, nurse Libby prepares to take emergency action to prevent the potential complication of: a. Thyroid storm. b. Cretinism. c. Myxedema coma. d. Hashimoto's thyroiditis.

C

During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? a. 40-year-old with chronic pancreatitis who has gnawing abdominal pain b. 58-year-old who has compensated cirrhosis and is complaining of anorexia c. 55-year-old with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) d. 36-year-old recovering from a laparoscopic cholecystectomy who has severe shoulder pain

C

In the administration of a drug such as levothyroxine (Synthroid), the nurse should teach the client: A) That therapy typically lasts about 6 months. B) That weekly laboratory tests for T4 levels will be required. C) To report weight loss, anxiety, insomnia, and palpitations. D) That the drug may be taken every other day if diarrhea occurs.

C

The condition of a patient who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the patient has developed liver cancer? A. Serum α-fetoprotein level B. Ventilation/perfusion scan C. Hepatic structure ultrasound D. Abdominal girth measurement

C

The nurse provides discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? A. "It is safe to take acetaminophen up to four times a day for pain." B. "Lactulose (Cephulac) should be taken every day to prevent constipation." C. "Herbs and other spices should be used to season my foods instead of salt." D. "I will eat foods high in potassium while taking spironolactone (Aldactone)."

C

The nurse smells a sweet fruity odor on the breath of a client admitted with DM. This odor may be associated with? a. alcohol intoxication b. insulin shock c. ketoacidosis d. macrovacular complications

C

The nurse will teach a patient with chronic pancreatitis to take the prescribed pancrelipase (Viokase) a. at bedtime. b. in the morning. c. with each meal. d. for abdominal pain.

C

When taking the blood pressure (BP) on the right arm of a patient with severe acute pancreatitis, the nurse notices carpal spasms of the patient's right hand. Which action should the nurse take next? a. Ask the patient about any arm pain. b. Retake the patient's blood pressure. c. Check the calcium level in the chart. d. Notify the health care provider immediately.

C

Which question will provide the most useful information to a nurse who is interviewing a patient about a possible thyroid disorder? A. "What methods do you use to help cope with stress?" B. "Have you experienced any blurring or double vision?" C. "Have you had a recent unplanned weight gain or loss?" D. "Do you have to get up at night to empty your bladder?"

C

. A 67-year-old male patient with acute pancreatitis has a nasogastric (NG) tube to suction and is NPO. Which information obtained by the nurse indicates that these therapies have been effective? a. Bowel sounds are present. b. Grey Turner sign resolves. c. Electrolyte levels are normal. d. Abdominal pain is decreased.

D

A 51-year-old woman had an incisional cholecystectomy 6 hours ago. The nurse will place the highest priority on assisting the patient to a. choose low-fat foods from the menu. b. perform leg exercises hourly while awake. c. ambulate the evening of the operative day. d. turn, cough, and deep breathe every 2 hours.

D

A nurse is completing nutrition teaching for a client who has pancreatitis. Which of the following statements by the client requires further teaching? A. "I plan to eat small, frequent meals." B. "I will eat easy-to-digest foods with limited spice." C. "I will use skim milk when cooking." D. "I plan to drink regular cola."

D

The family of a patient newly diagnosed with hepatitis A asks the nurse what they can do to prevent becoming ill themselves. Which response by the nurse is most appropriate? A. "The hepatitis vaccine will provide immunity from this exposure and future exposures." B. "I am afraid there is nothing you can do since the patient was infectious before admission." C. "You will need to be tested first to make sure you don't have the virus before we can treat you." D. "An injection of immunoglobulin will need to be given to prevent or minimize the effects from this exposure."

D

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? A. Impaired skin integrity related to edema, ascites, and pruritus B. Imbalanced nutrition: less than body requirements related to anorexia C. Excess fluid volume related to portal hypertension and hyperaldosteronism D. Ineffective breathing pattern related to pressure on diaphragm and reduced lung volume

D

Which data will the nurse monitor in relation to the 4+ pitting edema assessed in a patient with cirrhosis? a. Hemoglobin b. Temperature c. Activity level d. Albumin level

D

Which nursing diagnosis takes highest priority for a female client with hyperthyroidism? A. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess B. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing C. Body image disturbance related to weight gain and edema D. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

D

A client newly diagnosed with diabetes mellitus is having difficulty learning the technique of blood glucose measurement. The nurse should teach the client to do which of the following to perform the procedure properly? 1. Wash the hands first using cold water. 2. Puncture the center of the finger pad. 3. Puncture the finger as deeply as possible. 4. Let the arm hang dependently and milk the digit.

4

A client with myxedema has changes in intellectual function such as impaired memory, decreased attention span, and lethargy. The client's husband is upset and shares his concerns with the nurse. Which statement by the nurse is helpful to the client's husband? 1. "Would you like me to ask the health care provider for a prescription for a stimulant?" 2. "Give it time. I've seen dozens of clients with this problem that fully recover." 3. "I don't blame you for being frustrated, because the symptoms will only get worse." 4. "It's obvious that you are concerned about your wife's condition, but the symptoms may improve with continued therapy."

4

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia. Which statement by the client indicates a correct understanding of NPH insulin and exercise? 1. "I should not exercise after lunch." 2. "I should not exercise after breakfast." 3. "I should not exercise in the late evening." 4. "I should not exercise in the late afternoon."

4

A patient with cholelithiasis needs to have the gallbladder removed. Which patient assessment is a contraindication for a cholecystectomy? A. Low-grade fever of 100° F and dehydration B. Abscess in the right upper quadrant of the abdomen C. Activated partial thromboplastin time (aPTT) of 54 seconds D. Multiple obstructions in the cystic and common bile duct

C

Which laboratory test result will the nurse monitor when evaluating the effects of therapy for a 62-year-old female patient who has acute pancreatitis? a. Calcium b. Bilirubin c. Amylase d. Potassium

C

During preoperative teaching for a female client who will undergo subtotal thyroidectomy, the nurse should include which statement? A. "The head of your bed must remain flat for 24 hours after surgery." B. "You should avoid deep breathing and coughing after surgery." C. "You won't be able to swallow for the first day or two." D. "You must avoid hyperextending your neck after surgery."

D

The nurse will ask a 64-year-old patient being admitted with acute pancreatitis specifically about a history of a. diabetes mellitus. b. high-protein diet. c. cigarette smoking. d. alcohol consumption.

D

Which nursing diagnosis takes highest priority for a female client with hyperthyroidism? a. Risk for imbalanced nutrition: More than body requirements related to thyroid hormone excess b. Risk for impaired skin integrity related to edema, skin fragility, and poor wound healing c. Body image disturbance related to weight gain and edema d. Imbalanced nutrition: Less than body requirements related to thyroid hormone excess

D

A nurse is reviewing nutrition teaching for a client who has cholecystitis. Which of the following food choices can trigger cholecystitis? A. Brownie with nuts B. Bowl of mixed fruit C. Grilled turkey D. Baked potato

a

When providing discharge teaching for the patient after a laparoscopic cholecystectomy, what information should the nurse include? A. A lower-fat diet may be better tolerated for several weeks. B. Do not return to work or normal activities for 3 weeks. C. Bile-colored drainage will probably drain from the incision. D. Keep the bandages on and the puncture site dry until it heals

a

0. Which assessment finding would the nurse need to report most quickly to the health care provider regarding a patient with acute pancreatitis? a. Nausea and vomiting b. Hypotonic bowel sounds c. Abdominal tenderness and guarding d. Muscle twitching and finger numbness

d