Adults 1 Quizzes
Which question will the nurse ask the client to help determine the cause of hypokalemia?
"Do you use diuretics or laxatives?"
Which is the correct answer to a patient's question about the best site for self-administration of insulin?
Abdomen, because of rapid absorption from this area
Exercise in a person with diabetes is best performed
After meals
Which action will the nurse take in order to evaluate the effectiveness of Buck's traction for a patient who has an intracapsular fracture of the left femur?
Ask about left hip pain level Buck's traction keeps the leg immobilized and reduces painful muscle spasm. Hip contractures and dislocation are unlikely to occur in this situation. The peripheral pulses will be assessed, but this does not help in evaluating the effectiveness of Buck's traction.
Which action should the nurse take first when planning a moderate intensity exercise program for a diabetic patient?
Determine what type of exercise activities the patient enjoys Assessment of the patients preferred activities should occur first so that these activities can be incorporated into the teaching plan
In preparing a staff inservice presentation about diabetes mellitus, the nurse includes which information?
Diabetes increases the risk for development of cardiovascular disease. Diabetes mellitus is a major risk factor for morbidity and mortality caused by coronary artery disease, cerebrovascular disease, and peripheral vascular disease
Which clinical manifestations support the presence of hypoglycemia?
Diaphoresis and complaints of weakness
The nurse obtains the following assessment data in a 76-year-old patient who has influenza. Which information will be most important to communicate to the health care provider?
Diffuse crackles in the lungs The crackles indicate that the patient may be developing pneumonia, a common complication of influenza, which would require aggressive treatment. Myalgia, headache, mild temperature elevation, and sore throat with cough are typical symptoms of influenza and are treated with supportive care measures such as over-the-counter (OTC) pain relievers and increased fluid intake.
You are assessing a patient suspected of having isolated right-sided heart failure. What assessment finding may indicate right-sided heart failure?
Distended neck veins Distended neck veins result from back-up of blood from the right atrium and venous sytemic circulation. The other answers are assessment findings in left-sided heart failure.
A patient with type 1 diabetes mellitus is seeing the nurse to review foot care. What would be a priority instruction for the nurse to give the patient?
Do not use hot-water bottles and heating pads High-risk behaviors, such as walking barefoot, using heating pads on the feet, wearing open-toed shoes, soaking the feet, and shaving calluses, should be avoided. Socks should be worn for warmth. Feet should be examined each day for cuts, blisters, swelling, redness, tenderness, and abrasions. Lotion should be applied to dry feet but never between the toes. After a bath, the patient should gently, not vigorously, pat feet dry to avoid injury.
The circulating nurse performs which of the following functions?
Documents the assessment and plan of care, reports relevant information to the nurses in the PACU,
Which statement about glucagon is true?
Glucagon increases blood glucose by stimulating glycogenolysis, gluconeogenesis, and ketogenesis Glycogen is a counterregulatory hormone secreted by the alpha cells of the pancreas when blood glucose levels are low. The actions of glycogen that raise blood glucose levels include stimulating the liver to break down glycogen (glycogenolysis) and forming new glucose from protein breakdown (gluconeogenesis)
Which information will the nurse include when teaching a patient who has type 2 diabetes about glyburide (Micronase, DiaBeta, Glynase)?
Glyburide stimulates insulin production from the pancreas. The sulfonylureas stimulate the production and release of insulin from the pancreas. If the glucose level is low, the patient should contact the health care provider before taking the glyburide, because hypoglycemia can occur with this category of medication. Metformin should be held for 48 hours after administration of IV contrast media, but this is not necessary for glyburide. Glucagon secretion is not affected by glyburide
Surgery is almost completed for the patient, and the surgeon prepares to close a large abdominal incision. What will the scrub nurse prepare to do?
Hand sutures or a skin stapler to the surgeon
Which finding, if present, is consistent with a diagnosis of unstable angina?
Increased frequency and intensity of chest pain Unstable angina is chest pain that is new in onset, occurs at rest, or has a worsening pattern
How should an unconscious patient be positioned in the PACU?
Lateral (side-lying)
The nurse closely monitors for respiratory arrest in the patient receiving intravenous magnesium. An early indicator of too much magnesium is reflected in:
Loss of deep tendon reflexes
Which menu choice by a patient with osteoporosis indicates that the nurse's teaching about appropriate diet has been effective?
Oatmeal with skim milk and fruit yogurt Skim milk and yogurt are high in calcium. The other choices do not contain any high calcium foods.
Which are considered classic clinical manifestations of type 1 diabetes mellitus?
Polydipsia, polyuria, and polyphagia
The main purpose of applying graduated compression stockings and sequential compression devices following major surgery is to:
Promote venous return
A 67-year-old patient tells the nurse, "I have problems with constipation now that I am older, so I use a suppository every morning." Which action should the nurse take first?
Question the patient about individual risk factors for constipation. The nurse's initial action should be further assessment of the patient for risk factors for constipation and for usual bowel pattern. The other actions may be appropriate but will be based on the assessment.
Which assessment finding about a patient who has been using naproxen (Naprosyn) for 3 weeks to treat osteoarthritis is most important for the nurse to report to the health care provider?
The patient has dark black, tarry stools Dark colored stools may indicate that the patient is experiencing gastrointestinal bleeding caused by the naproxen. The information about the patient's ongoing pain and weight gain also will be reported and may indicate a need for a different treatment and/or counseling about avoiding weight gain, but these are not as large a concern as the possibility of gastrointestinal bleeding. Use of capsaicin cream with oral medications is appropriate.
A patient with type 2 diabetes is admitted for an outpatient coronary arteriogram and is planned to receive IV contrast media. Which information obtained by the nurse is most important to report to the health care provider before the procedure?
The patient took a dose of Metformin (Glucophage) this morning
True or False: Principles of good nutrition for the general population also apply to people with diabetes mellitus
True
A patient's family history reveals that the patient may be at risk for malignant hyperthermia (MH) during anesthesia. The nurse explains to the patient that
anesthesia can be administered with minimal risks with the use of appropriate precautions and medications.
When teaching a patient with renal failure about a low phosphate diet, the nurse will include information to restrict
ingestion of dairy products.
The nurse has finished teaching a patient about the use of sublingual nitroglycerin (Nitrostat) for angina. Which patient statement indicates that the teaching has been effective?
" I will call 911 if I have pain 5 minutes after taking nitroglycerin." The emergency medical services (EMS) system should be activated when chest pain or other symptoms are not completely relieved 5 minutes after taking one nitroglycerin. Nitroglycerin can be taken to prevent chest pain or other symptoms from developing (e.g., before intercourse). Gastric upset is not an expected side effect of nitroglycerin. Nitroglycerin does not impact the underlying pathophysiology of coronary artery atherosclerosis.
Which question by the nurse will help identify autonomic neuropathy in a diabetic patient?
"Do you notice any bloating or feeling of fullness after eating?" Autonomic neuropathy can cause delayed gastric emptying, which results in a bloated feeling for the patient. The other questions also are appropriate to ask, but would not help in identifying autonomic neuropathy.
The nurse has initiated discharge teaching for a patient who is to be maintained on warfarin (Coumadin) following hospitalization for venous thromboembolism (VTE). The nurse determines that additional teaching is needed when the patient says,
"I should vary the amount of green, leafy vegetables that I eat." Patients taking Coumadin are taught to follow a consistent diet with regard to foods that are high in vitamin K, such as green, leafy vegetables. The other patient statements are accurate.
The Diabetic Educator is discussing "sick day rules" with a newly diagnosed type 1 diabetic. The Educator is aware that the patient will require further teaching when the patient states
"I will not take my insulin on the days when I am sick, but I will check my blood sugar every 2 hours." The nurse must explanation the "sick day rules" again to the patient. The nurse should emphasize that the patient should take insulin agents as usual and test their blood sugar and urine ketones every 3 to 4 hours. In fact, insulin-requiring patients may need supplemental doses of regular insulin every 3 to 4 hours. The patient should report elevated glucose levels (greater than 300 mg/dL or as otherwise instructed) or urine ketones to the physician. If the patient is not able to eat normally, the patient should be instructed to substitute soft foods such a gelatin, soup and pudding. If vomiting, diarrhea or fever persists, the patient should have an intake of liquids every 1/2 hour to hour to prevent dehydration. Fluid loss is dangerous and nausea, vomiting, and diarrhea should be reported to the physician. Patients with type 1 diabetes who cannot retain oral fluids may need hospitalization to avoid diabetic ketoacidosis and possibly coma.
Which chart entry for a patient with venous insufficiency records appropriate nursing intervention?
"Legs elevated while up in chair"
Which statement made by a patient would alert the nurse to the possibility of right-sided heart failure?
"My shoes fit really tight." Peripheral edema is common with right-sided heart failure.
A 35-year-old patient with three school-age children who has recently been diagnosed with rheumatoid arthritis (RA) tells the nurse that the inability to be involved in many family activities is causing stress at home. Which initial response by the nurse is most appropriate?
"Tell me more about the situations that are causing stress." The initial action by the nurse should be further assessment. The other three responses might be appropriate based on the information the nurse obtains with further assessment.
A patient with a venous thromboembolism (VTE) is started on enoxaparin (Lovenox) and warfarin (Coumadin). The patient asks the nurse why two medications are necessary. Which response by the nurse is accurate?
"The Lovenox will work immediately, but the Coumadin takes several days to have an effect on coagulation." Low molecular weight heparin (LMWH) is used because of the immediate effect on coagulation and discontinued once the international normalized ratio (INR) value indicates that the warfarin has reached a therapeutic level. LMWH has no thrombolytic properties. The use of two anticoagulants is not related to the risk for pulmonary embolism, and two are not necessary to reduce the risk for another VTE
A patient is admitted with chest pain. Which question is designed to determine the precipitating event?
"What were you doing when the pain started?"
Prehypertension, a precursor to hypertension, can be diagnosed when the diastolic reading is between
80-89 mm Hg Prehypertension is described as a SBP of 120-139 and/or a DBP of 80-89 mm Hg.
A patient receives aspart (NovoLog) insulin at 8:00 AM. Which time will it be most important for the nurse to monitor for symptoms of hypoglycemia?
9:00 AM The rapid-acting insulins peak in 1 to 3 hours. The patient is not at a high risk for hypoglycemia at the other listed times, although hypoglycemia may occur.
The nurse identifies which patient is at risk to develop metabolic alkalosis?
A patient with continuous nasogastric suctioning Excessive nasogastric suctioning may cause metabolic alkalosis. Type 1 diabetes mellitus (diabetic ketoacidosis) is associated with metabolic acidosis. Acute respiratory failure may lead to respiratory acidosis, and brain injury may cause hyperventilation and respiratory alkalosis.
An 88-year-old with benign prostatic hyperplasia (BPH) has a markedly distended bladder and is agitated and confused. Which of the following interventions prescribed by the health care provider should the nurse implement first?
Administer lorazepam (Ativan) 0.5 mg PO The patient's history and clinical manifestations are consistent with acute urinary retention, and the priority action is to relieve the retention by catheterization. The BUN and creatinine measurements can be obtained after the catheter is inserted. The patient's agitation may resolve once the bladder distention is corrected, and sedative drugs should be used cautiously in older patients. The IVP is an appropriate test, but does not need to be done urgently.
The perioperative nurse is supervising the surgical technologist before the arrival of the patient in the operating room. Which action, if taken by the surgical technologist, would require the nurse to intervene?
After a surgical scrub, the surgical technologist puts on a sterile gown and one pair of sterile gloves. Once a surgical hand scrub is completed, the surgical technologist should put on a sterile surgical gown and two pairs of gloves to prevent the transmission of microorganisms. Surgical hand antisepsis is completed by scrubbing fingers and hands first followed by progression to forearms and elbows. The hands should be held away from surgical attire and higher than the elbows at all times to prevent contamination. After performing a surgical hand scrub and applying a sterile gown and two pairs of sterile gloves, the person may manipulate and organize all sterile items for use during the procedure
One mechanism that is responsible for blood pressure elevation is:
Alterations in the Renin-Angiotensin-Aldosterone mechanism
Which topic will the nurse include in patient teaching for a patient with a venous stasis ulcer on the right lower leg?
Application of compression to the leg Compression of the leg is essential to healing of venous stasis ulcers. High dietary intake of protein, rather than carbohydrates, is needed. Prophylactic antibiotics are not routinely used for venous ulcers. Moist environment dressings are used to hasten wound healing.
When administering sublingual nitroglycerin (nitroglycerin) to a patient with unstable angina, which action will the nurse take to evaluate the effectiveness of the medication?
Assess chest pain The goal of nitroglycerin administration for angina is relief of chest pain by improving the balance between myocardial oxygen supply and demand. The nurse also will monitor heart rate and BP and observe for dysrhythmias, but these parameters will not indicate whether the medication is effective.
A patient with a serum potassium level of 2.9 mEq/L is to receive an IV bolus of potassium chloride. An essential step in this procedure is to:
Assess the IV site hourly
A 78-year-old who has been admitted to the hospital with dehydration is confused and incontinent of urine. Which nursing action will be best to include in the plan of care?
Assist the patient to the bathroom every 2 hours during the day. In older or confused patients, incontinence may be avoided by using scheduled toileting times. Indwelling catheters increase the risk for urinary tract infection (UTI). Incontinent pads increase the risk for skin breakdown. Restricting fluids is not appropriate in a patient with dehydration.
A patient with a history of chronic heart failure is admitted to the emergency department (ED) with severe dyspnea and a dry, hacking cough. Which action should the nurse take first?
Auscultate breath sounds This patient's severe dyspnea and cough indicate that acute decompensated heart failure (ADHF) is occurring. ADHF usually manifests as pulmonary edema, which should be detected and treated immediately to prevent ongoing hypoxemia and cardiac/respiratory arrest. The other assessments will provide useful data about the patient's volume status and also should be accomplished rapidly, but detection (and treatment) of pulmonary complications is the priority.
A patient who was admitted the previous day with pneumonia complains of a sharp pain "whenever I take a deep breath." Which action will the nurse take next?
Auscultate to the patient's lungs The patient's statement indicates that pleurisy or a pleural effusion may have developed and the nurse will need to listen for a pleural friction rub and/or decreased breath sounds. Assessment should occur before administration of pain medications. The patient is unlikely to be able to cough forcefully until pain medication has been administered. The nurse will want to obtain more assessment data before calling the health care provider.
Which laboratory test is best to determine the effects of therapy for a patient being treated for heart failure?
B-type natriuretic peptide (BNP) Increased levels of BNP are a marker for heart failure. The other laboratory results would be used to assess for myocardial infarction (myoglobin) or risk for coronary artery disease (Hcy and LDL).
Which situation best meets the criteria for diagnosing hypertension?
BP 144/94 mm Hg supine and sitting for 3 consecutive weeks HTN is defined as a persistent SBP greater than or equal to 140 and a DBP greater than or equal to 90, or current use of antihypertensive medication
Which topic will the nurse plan to include in discharge teaching for a patient with systolic heart failure and an ejection fraction of 38%?
Benefits and side effects of angiotensin-converting enzyme (ACE) inhibitors ACE Inhibitors are the primary drug of choice for blocking the RAAS system in HF patients with systolic dysfunction. Salt substituts increase the risk of hyperkalemia. Walking and other activities should be increased gradually, provided they don't cause fatigue or dyspnea. Aerobic exercise may increase cardiac workload to a dangerous level.
In teaching a hypertensive client about the side effects of propranolol (Inderal) the nurse plans to include which side effect of this medication therapy?
Bradycardia Beta Blockers, such as Propanolol, cause a decrease in heart rate and decreased contractility, which can result in bradycardia or heart failure. Constipation is a side effect with some of the calcium channel blockers, while hypokalemia increases risk of digitalis toxicity.
A patient in the hospital has a history of functional urinary incontinence. Which nursing action will be included in the plan of care?
Place a bedside commode near the patient's bed. Modifications in the environment make it easier to avoid functional incontinence. Checking for residual urine and performing the Credé maneuver are interventions for overflow incontinence. Kegel exercises are useful for stress incontinence.
When assessing a patient with Alzheimer's disease (AD) who is being admitted to a long-term care facility, the nurse learns that the patient has had several episodes of wandering away from home. Which nursing action is best to include in the plan of care?
Place the patient in a room close to the nurses' station. Patients at risk for problems with safety require close supervision. Placing the patient near the nurse's station will allow nursing staff to observe the patient more closely. The use of "why" questions is frustrating for patients with AD because they are unable to understand clearly or verbalize the reason for wandering behaviors. Because of the patient's short-term memory loss, reorientation will not help prevent wandering behavior. Because the patient had wandering behavior at home, familiar objects will not prevent wandering.
A hospitalized patient who has been taking antibiotics for several days develops watery diarrhea. Which action should the nurse take first?
Place the patient on contact precautions The patient's history and new onset diarrhea suggest a C. difficile infection, which requires implementation of contact precautions to prevent spread of the infection to other patients. The other actions also are appropriate but can be accomplished after contact precautions are implemented.
Which signs and symptoms does a nurse expect to see in a patient with a fluid volume deficit?
Postural hypotension and dry mucous membranes
A nurse plans care for a client with Chronic Obstructive Pulmonary Disease (COPD) with the understanding that the patient is most likely to experience which acid-base imbalance?
Respiratory Acidosis
A patient has recently started taking oral digoxin (Lanoxin) in addition to furosemide (Lasix) and captopril (Capoten) for control of heart failure. Which assessment finding by the home health nurse is most important to communicate to the health care provider?
Serum potassium level is 3.0 mEq/L after 1 week of therapy Hypokalemia can predispose the patient to life-threatening dysrhythmias (e.g., premature ventricular contractions), and potentiate the actions of digoxin and increase the risk for digoxin toxicity, which also can cause life-threatening dysrhythmias. The other data indicate that the patient's heart failure requires more effective therapies, but they do not require nursing action as rapidly as the low serum potassium level.
Which clinical manifestations help confirm the presence of pulmonary edema?
Severe dyspnea, blood-tinged sputum, and wheezing
Which dietary restriction is used to treat edema associated with chronic heart failure?
Sodium
Which type of anesthesia can be used when a patient wishes to be fully conscious during a surgical procedure?
Spinal anesthesia
A home health patient with rheumatoid arthritis (RA) complains to the nurse about having chronically dry eyes. Which action by the nurse is most appropriate?
Suggest that the patient start using over-the-counter (OTC) artificial tears. The patient's dry eyes are consistent with Sjögren's syndrome, a common extraarticular manifestation of RA. Symptomatic therapy such as OTC eye drops is recommended. Dry eyes are not a side effect of methotrexate. Although dry eyes are common in RA, it is more helpful to offer a suggestion to relieve these symptoms than to offer reassurance. The dry eyes are not caused by RA treatment, but by the disease itself.
When caring for a patient with a new diagnosis of rheumatoid arthritis, which action will the nurse include in the plan of care?
Suggest that the patient take a nap in the afternoon. Adequate rest helps decrease the fatigue and pain that are associated with rheumatoid arthritis. Patients are taught to not use pillows under knees to prevent contracture, to use warm baths to relieve stiffness, and to use a firm mattress.
Which of the following actions are performed during a surgical time-out?
The patient is asked to state the surgical procedure and location, the patient is asked to state his name and date of birth, the hospital identification number is verified with the patient's identification band
The nurse is caring for a patient who had surgery 24 hours ago. Which is the best indicator for the nurse to know that the patient's pain is well controlled?
The patient states she has no pain.
Which information given by a patient admitted with chronic stable angina will help the nurse confirm this diagnosis?
The patient states that the pain is resolved after taking one sublingual nitroglycerin tablet. Chronic stable angina is typically relieved by rest or nitroglycerin administration. The level of pain is not a consistent indicator of the type of angina. Pain occurring at rest or with increased frequency is typical of unstable angina.
Aspirin is ordered for a patient who is admitted with a possible stroke. Which information obtained during the admission assessment indicates that the nurse should consult with the health care provider before giving the aspirin?
The patient states, "My symptoms started with a terrible headache." A sudden onset headache is typical of a subarachnoid hemorrhage, and aspirin is contraindicated. Atrial fibrillation, dysphasia, and transient ischemic attack (TIA) are not contraindications to aspirin use, so the nurse can administer the aspirin.
Which information about a patient who is being treated with carbidopa/levodopa (Sinemet) for Parkinson's disease is most important for the nurse to report to the health care provider?
Uncontrolled head movement Dyskinesia is an adverse effect of the Sinemet, indicating a need for a change in medication or decrease in dose. The other findings are typical with Parkinson's disease.
When discussing risk factor modification for a 60-year-old patient who has a 4-cm abdominal aortic aneurysm, the nurse will focus patient teaching on which of these patient risk factors?
Uncontrolled hypertension All of the factors contribute to the patient's risk, but only the hypertension can potentially be modified to decrease the patient's risk for further expansion of the aneurysm.
Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which information best supports this diagnosis?
Weak, nonproductive cough effort The weak, nonproductive cough indicates that the patient is unable to clear the airway effectively. The other data would be used to support diagnoses such as impaired gas exchange and ineffective breathing pattern.
The nurse monitors for which complication in a patient taking a nonselective beta-blocking agent?
Wheezing Nonselective beta blockers can cause bronchoconstriction and impair respiratory effort. Patients with pre-existing pulmonary problems should not take nonselective beta-blocking agents. Patients who develop bronchoconstriction should have their therapy changed
The nurse teaches the diabetic patient who rides a bicycle to work every day to administer morning insulin into the
abdomen Patients should be taught not to administer insulin into a site that will be exercised because exercise will increase the rate of absorption. The thigh, buttock, and arm are all exercised by riding a bicycle
The following medications are prescribed by the health care provider for a patient having an acute asthma attack. Which one will the nurse administer first?
albuterol (Ventolin) 2.5 mg per nebulizer Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications work more slowly.
The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and regains consciousness immediately. It will be most important for the nurse to
assess the patient for a possible head injury The patient who has had a myoclonic seizure and fall is at risk for head injury and should be evaluated and treated for this possible complication first. Documentation of the seizure, notification of the seizure, and administration of antiseizure medications also are appropriate actions, but the initial action should be assessment for injury.
A patient at the clinic says, "I have always taken an evening walk, but lately my leg cramps and hurts after just a few minutes of walking. The pain goes away after I stop walking, though." The nurse should
attempt to palpate the dorsalis pedis and posterior tibial pulses. The nurse should assess for other clinical manifestations of peripheral arterial disease in a patient who describes intermittent claudication. Changes in skin color that occur in response to cold are consistent with Raynaud's phenomenon. Tortuous veins on the legs suggest venous insufficiency. Unilateral leg swelling, redness, and tenderness point to venous thromboembolism (VTE).
A patient who has type 1 diabetes plans to take a swimming class daily at 1:00 PM. The clinic nurse will plan to teach the patient to
check glucose level before, during, and after swimming The change in exercise will impact blood glucose. The patient will need to monitor glucose carefully to determine the need for changes in diet and insulin administration. Because exercise tends to decrease blood glucose, patients are advised to eat before exercising. The other measures further increase the risk of hypoglycemia.
A patient with type 1 diabetes has been using self-monitoring of blood glucose (SMBG) as part of diabetes management. During evaluation of the patient's technique of SMBG, the nurse identifies a need for additional teaching when the patien
chooses a puncture site in the center of the finger pad The patient is taught to choose a puncture site at the side of the finger pad. The other patient actions indicate that teaching has been effective.
Primary risk factors for heart failure include:
coronary artery disease and advanced age
During the initial postoperative assessment of a patient's stoma formed from a transverse colostomy, the nurse finds it to be rosy red with moderate edema and a small amount of bleeding. The nurse should
document the stoma assessment. The stoma appearance indicates good circulation to the stoma. There is no indication that surgical intervention is needed or that frequent stoma monitoring is required. Swelling of the stoma is normal for 2 to 3 weeks after surgery, and an ice pack is not needed.
The majority of the body's water is located in the
intracellular fluid Approximately 2/3 of the body's water is located within the cells.
An assessment finding that alerts the nurse to the presence of osteoporosis in a middle-aged patient is
measurable loss of height Osteoporosis occurring in the vertebrae produces a gradual loss of height. Bowed legs are associated with osteomalacia. Low intake of dairy products is a risk factor for osteoporosis, but it does not indicate that osteoporosis is present. Frequent falls increase the risk for fractures but are not an indicator of osteoporosis.
A patient with chronic obstructive pulmonary disease (COPD) has a nursing diagnosis of imbalanced nutrition: less than body requirements. An appropriate intervention for this problem is to
offer high calorie snacks between meals and at bedtime Pages 624-625 Eating small amounts more frequently (as occurs with snacking) will increase caloric intake by decreasing the fatigue and feelings of fullness associated with large meals. Patients with COPD should rest before meals. Foods that have a lot of texture may take more energy to eat and lead to decreased intake. Although fruits and juices are not contraindicated, foods high in protein are a better choice.
The nurse expects that management of the patient who experiences a brief episode of tinnitus, diplopia, and dysarthria with no residual effects will include
oral administration of low dose aspirin therapy The patient's symptoms are consistent with transient ischemic attack (TIA), and drugs that inhibit platelet aggregation are prescribed after a TIA to prevent stroke. Continuous heparin infusion is not routinely used after TIA or with acute ischemic stroke. The patient's symptoms are not consistent with a cerebral aneurysm. tPA is used only for acute ischemic stroke, not for TIA.
The nurse is caring for a patient who is receiving IV furosemide (Lasix) and morphine for the treatment of acute decompensated heart failure (ADHF) with severe orthopnea. When evaluating the patient response to the medications, the best indicator that the treatment has been effective is
relief of dyspnea when the head of bed is elevated. Because the patient's major clinical manifestation of ADHF is orthopnea (caused by the presence of fluid in the alveoli), the best indicator that the medications are effective is a decrease in dyspnea with the head of the bed at 30 degrees. The other assessment data also may indicate that diuresis has occurred but are not as specific to evaluating this patient's response.
A hospitalized diabetic patient who received 34 U of NPH insulin at 7:00 AM is away from the nursing unit, awaiting a series of x-rays when lunch trays are distributed. To prevent hypoglycemia, the best action by the nurse is to
request that the patient be returned to the unit to eat lunch if testing will not be completed promptly Consistency for mealtimes assists with regulation of blood glucose, so the best option is for the patient to have lunch at the usual time. Waiting to eat until after the procedure is likely to cause hypoglycemia. Administration of an IV solution is unnecessarily invasive for the patient. A glass of milk or juice will keep the patient from becoming hypoglycemic but will cause a rapid rise in blood glucose because of the rapid absorption of the simple carbohydrate in these items.
A patient with type 2 diabetes that is well-controlled with metformin (Glucophage) develops an allergic rash to an antibiotic and the health care provider prescribes prednisone (corticosteroids). The nurse will anticipate that the patient may
require administration of insulin while taking prednisone Glucose levels increase when patients are taking corticosteroids, and insulin may be required to control blood glucose. Hypoglycemia is not a side effect of prednisone. Rashes are not an adverse effect caused by taking metformin and prednisone simultaneously. The patient may have an increased appetite when taking prednisone, but will not need a diet that is higher in calories.
A patient with a left-sided brain stroke suddenly bursts into tears when family members visit. The nurse should
teach the family that emotional outbursts are common after strokes. Patients who have left-sided brain stroke are prone to emotional outbursts, which are not necessarily related to the emotional state of the patient. Depression after a stroke is common, but the suddenness of the patient's outburst suggests that depression is not the major cause of the behavior. The family should stay with the patient. The crying is not within the patient's control and asking the patient to stop will lead to embarrassment.
A patient with hypertension has a blood pressure of 170/96 after 6 months of intensive exercise and diet modifications. The nurse advises the patient
to discuss the addition of medication therapy with the healthcare provider in addition to diet and exercise. BP should be consistently below 140/90. Lifestyle modification must be used in all hypertensive clients with or without medication therapy.
A staff nurse has a tuberculosis (TB) skin test of 16-mm induration. A chest radiograph is negative, and the nurse has no symptoms of TB. The occupational health nurse will plan on teaching the staff nurse about the
use and side effects of isoniazid (INH). The nurse is considered to have a latent TB infection and should be treated with INH daily for 6 to 9 months. The four-drug therapy would be appropriate if the nurse had active TB. TB skin testing is not done for individuals who have already had a positive skin test. BCG vaccine is not used in the United States and would not be helpful for this individual, who already has a TB infection.
To determine whether treatment is effective for a patient with primary open-angle glaucoma (POAG), the nurse will evaluate the patient for improvement in
visual field. POAG develops slowly and without symptoms except for a gradual loss of visual field. Acute closed-angle glaucoma may present with excruciating pain, colored halos, and blurred vision. Problems with depth perception are not associated with POAG.
A patient with newly diagnosed type 2 diabetes mellitus asks the nurse what "type 2" means in relation to diabetes. Which statement by the nurse about type 2 diabetes is correct?
Changes in diet and exercise may be sufficient to control blood glucose levels in type 2 diabetes. For some patients, changes in lifestyle are sufficient for blood glucose control. Insulin is frequently used for type 2 diabetes, complications are equally severe as for type 1 diabetes, and type 2 diabetes is usually diagnosed with routine laboratory testing or after a patient develops complications such as frequent yeast infections.
The nurse assesses for which modifiable risk factor in the patient with coronary artery disease?
Cigarette smoking Modifiable risk factors can be altered or controlled. Cigarette smoking and a sedentary lifestyle are examples of behaviors that are modifiable. Nonmodifiable factors are personal elements that cannot be altered or controlled (e.g., age, gender, family history).
A 72-year-old who has benign prostatic hyperplasia is admitted to the hospital with chills, fever, and vomiting. Which finding by the nurse will be most helpful in determining whether the patient has an upper urinary tract infection (UTI)?
Costovertebral tenderness Costovertebral tenderness is characteristic of pyelonephritis. The other symptoms are characteristic of lower UTI and are likely to be present if the patient also has an upper UTI.
The nurse is planning to instruct a client on the side effects of nifedipine (Procardia) for hypertension. Which side effect should the nurse include?
Dizziness Calcium channel blockers relax arterial smooth muscle, which lowers peripheral resistance through vasodilation. Dizziness is a common side effect because of the orthostatic hypotension. Clients need to be taught to change positions slowly to prevent falls.
Which nursing intervention best prevents postoperative complications?
Early ambulation
A patient with chronic obstructive pulmonary disease (COPD) has rhonchi throughout the lung fields and a chronic, nonproductive cough. Which nursing action will be most effective?
Educate the patient to use the Flutter airway clearance device. Pages 624-625 Airway clearance devices assist with moving mucus into larger airways where it can more easily be expectorated. The other actions may be appropriate for some patients with COPD, but they are not indicated for this patient's problem of thick mucous secretions.
During assessment of a 72-year-old with ankle swelling, the nurse notes jugular venous distention (JVD) with the head of the patient's bed elevated 45 degrees. The nurse knows this finding indicates
Elevated right atrial pressure The jugular veins empty into the superior vena cava and then into the right atrium, so JVD with the patient sitting at a 45-degree angle reflects elevated right atrial pressure. JVD is an indicator of excessive fluid volume (increased preload), not decreased fluid volume. JVD is not caused by incompetent jugular vein valves or atherosclerosis.
During a teaching session, the nurse emphasizes which aspect of foot care to the patient with peripheral artery disease (PAD)?
Examine the feet daily for skin breaks.
An older adult patient with presbycusis is fitted with binaural hearing aids. Which information will the nurse include when teaching the patient how to use the hearing aids?
Experiment with volume and hearing ability in a quiet environment initially. Initially the patient should use the hearing aids in a quiet environment like the home, experimenting with increasing and decreasing the volume as needed. There is no need to gradually increase the time of wear. The patient should experiment with the level of volume to find what works well in various situations. Both hearing aids should be used.
Which of the following would be best for a patient to consume in the event of hypoglycemia?
Fruit juice Fat delays the absorption of glucose, so it is best to administer simple carbohydrates
Which herb or supplement can increase the risk of bleeding in a surgical patient?
Garlic Feverfew, garlic, ginger, ginkgo biloba, ginseng and vitamin E can increase bleeding risks in surgical patients. See page 338.
To evaluate the effectiveness of treatment for a patient with type 2 diabetes who is scheduled for a follow-up visit in the clinic, which test will the nurse plan to schedule for the patient?
Glycosylated hemoglobin level (Hb A1C) The glycosylated hemoglobin (Hb A1C) test shows the overall control of glucose over 90 to 120 days. A fasting blood level indicates only the glucose level at one time. Urine glucose testing is not an accurate reflection of blood glucose level and does not reflect the glucose over a prolonged time. Oral glucose tolerance testing is done to diagnose diabetes, but is not used for monitoring glucose control once diabetes has been diagnosed.
Which electrolyte imbalances can cause digitalis toxicity?
Hypomagnesemia, hypercalcemia, hypokalemia
When discussing angina pectoris secondary to atherosclerotic disease with a patient, the patient asks why he experiences chest pain with exertion. The nurse informs the patient that exertion:
Increase the heart's oxygen demands Atherosclerosis involves plaque buildup and thrombus formation,which causes decreased oxygen delivery. This is most evident during exertional activities when more oxygen is required.
When Trousseau's sign is elicited during diagnostic tests for hypocalcemia, the nurse is:
Inflating a blood pressure cuff on the upper arm
The purpose of anticoagulant therapy in treating deep vein thrombosis is to:
Inhibit new clot formation
A patient seen in the asthma clinic has recorded daily peak flows that are 85% of the baseline. Which action will the nurse plan to take?
Instruct the patient to continue to use current medications. The patient's peak flow readings indicate good asthma control, and no changes are needed. The other actions would be used for patients in the yellow or red zones for peak flow. Page 608
A patient complains of left calf pain after walking around the block. The pain is immediately relieved when the patient sits down. The nurse analyzes this as:
Intermittent claudication Intermittent claudication is a classic symptom of lower extremity PAD--an ischemic muscle ache or pain that is precipitated by a consistent level of exercise and resolves within 10 minutes or less with rest, and is reproducible.
The nurse is caring for a patient planning dietary changes for the treatment of hypertension. Which dietary selections are appropriate?
Low-fat milk, grilled chicken or fish, fresh fruit
Which oral medication for type 2 diabetes needs to bel held 1-2 days before and 48 hours after IV contrast media is given?
Metformin (Glucophage)
A major reason for the accumulation of fluid in the interstitial space of patients with low plasma protein content is:
Decreased plasma oncotic pressure
