AH2 theory final
A client diagnosed with hyperosmolar hyperglycemic nonketotic syndrome (HHNS) is stabilized and prepared for discharge. When preparing the client for discharge and home management, which statement indicates that the client understands his condition and how to control it? "I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual." "If I experience trembling, weakness, and headache, I should drink a glass of soda that contains sugar." "I will have to monitor my blood glucose level closely and notify the physician if it's constantly elevated." "If I begin to feel especially hungry and thirsty, I'll eat a snack high in carbohydrates."
"I can avoid getting sick by not becoming dehydrated and by paying attention to my need to urinate, drink, or eat more than usual."
The nurse is caring for a patient that has developed oliguria. Oliguria is defined as urine output less than ___________mL/kg/hr.
0.5
A nurse is preparing a continuous insulin infusion for a child with diabetic ketoacidosis and a blood glucose level of 800 mg/dl. Which solution is the most appropriate at the beginning of therapy? 100 units of regular insulin in normal saline solution 100 units of neutral protamine Hagedorn (NPH) insulin in normal saline solution 100 units of regular insulin in dextrose 5% in water 100 units of NPH insulin in dextrose 5% in water
100 units of regular insulin in normal saline solution
A nurse is teaching a client with diabetes mellitus about self-management of his condition. The nurse should instruct the client to administer 1 unit of insulin for every: 10 g of carbohydrates. 15 g of carbohydrates. 20 g of carbohydrates. 25 g of carbohydrates.
15 g carbohydrates
The nurse taking care of a patient evidencing signs of shock empties the urinary catheter drainage bag after her 12-hour shift. The nurse notes an indicator of renal hypoperfusion. What is the relevant urinary output for this condition? 300 mL 400 mL 500 mL 600 mL
300 mL
Which blood pressure (BP) reading would result in a pulse pressure indicative of shock? 120/90 mm Hg 90/70 mm Hg 130/90 mm Hg 100/60 mm Hg
90/70 mm Hg
The nurse is monitoring the patient in shock. The patient begins bleeding from previous venipuncture sites, in the indwelling catheter, and rectum, and the nurse observes multiple areas of ecchymosis. What does the nurse suspect has developed in this patient? Stress ulcer Disseminated intravascular coagulation (DIC) Septicemia Stevens-Johnson syndrome from the administration of antibiotics
DIC
A nurse who provides care in an ambulatory clinic integrates basic cancer screening into admission assessments. What client most likely faces the highest immediate risk of oral cancer? A 65-year-old man with alcoholism who smokes A 45-year-old woman who has type 1 diabetes and who wears dentures A 32-year-old man who is obese and uses smokeless tobacco A 57-year-old man with GERD and dental caries
a 65 year old man with alcoholism who smokes
A client reports chest pain and heavy breathing when exercising or when stressed. Which is a priority nursing intervention for the client diagnosed with coronary artery disease? a. Assess chest pain and administer prescribed drugs and oxygen b. Assess blood pressure and administer aspirin c. It is not important to assess the client or to notify the physician d. Assess the client's physical history
a. Assess chest pain and administer prescribed drugs and oxygen
Based on the pathophysiologic changes that occur as renal failure progresses, the nurse identifies the following indicators associated with the disease. Select all that apply. a. Hyperkalemia b. Metabolic alkalosis c. Anemia d. Hyperalbuminemia e. Hypocalcemia
a. Hyperkalemia c. Anemia e. Hypocalcemia
A nurse is evaluating a client who had a myocardial infarction (MI) 7 days earlier. Which outcome indicates that the client is responding favorably to therapy? a. The client demonstrates ability to tolerate more activity without chest pain. b. The client exhibits a heart rate above 100 beats/minute. c. The client verbalizes the intention of making all necessary lifestyle changes except for stopping smoking. d. The client states that sublingual nitroglycerin usually relieves his chest pain.
a. The client demonstrates ability to tolerate more activity without chest pain.
The nurse is caring for a client with coronary artery disease (CAD). What is an appropriate nursing action when evaluating a client with CAD? a. Assess the client's mental and emotional status. b. Assess the skin of the client. c. Assess the characteristics of chest pain. d. Assess for any kind of drug abuse.
a. assess the characteristics of chest pain
A middle-aged client presents to the ED reporting severe chest discomfort. Which finding is most indicative of a possible myocardial infarction (MI)? a. chest discomfort not relieved by rest or nitroglycerin b. intermittent nausea and emesis for 3 days c. cool, clammy skin and diaphoretic, pale appearance d. anxiousness, restlessness, lightheadedness
a. chest discomfort not relieved by rest or nitroglycerin
A client diagnosed with heart failure presents with a temperature of 99.1° F, pulse 100 beats/minute, respirations 42 breaths/minute, BP 110/50 mm Hg; crackles in both lung bases; nausea; and pulse oximeter reading of 89%. Which finding indicates a need for immediate attention? a. lung congestion b. nausea c. temperature d. blood pressure
a. long congestion
A client with quadriplegia is in spinal shock. What finding should the nurse expect? Absence of reflexes along with flaccid extremities Positive Babinski's reflex along with spastic extremities Hyperreflexia along with spastic extremities Spasticity of all four extremities
absence of reflexes along with flaccid extremities
A nurse is caring for a terminally ill client who is receiving chemotherapy and radiation for an aggressive lung cancer. The treatment success is limited in shrinking the tumor, and the treatments are making the client very ill. The client states, "I feel that I would like to stop treatments. I would like to enjoy the time that I have remaining with my family." Which emotional reaction does the nurse recognize that the client is experiencing? Denial Bargaining Anger Acceptance
acceptance
A client is evaluated for severe pain in the right upper abdominal quadrant, which is accompanied by nausea and vomiting. The physician diagnoses acute cholecystitis and cholelithiasis. For this client, which nursing diagnosis takes top priority? Acute pain related to biliary spasms Deficient knowledge related to prevention of disease recurrence Anxiety related to unknown outcome of hospitalization Imbalanced nutrition: Less than body requirements related to biliary inflammation
acute pain related to biliary spasms
Which statement about fluid replacement is accurate for a client with hyperosmolar hyperglycemic nonketotic syndrome? Administer 2 to 3 L of IV fluid rapidly. Administer 10 L of IV fluid over the first 24 hours. Administer a dextrose solution containing normal saline solution. Administer IV fluid slowly to prevent circulatory overload and collapse.
administer 2-3 L of IVF rapidly
Constant bubbling in the water seal of a chest drainage system indicates which problem? Air leak Tidaling Tension pneumothorax Increased drainage
air leak
The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem? Air leak Tidaling Tension pneumothorax Increased drainage
air leak
A terminally ill client has feelings of rage toward the nurse. According to Elisabeth Kübler-Ross, the patient is in which stage of dying? Denial Anger Bargaining Depression
anger
A client with a history of chronic renal failure receives hemodialysis treatments three times per week through an arteriovenous (AV) fistula in the left arm. Which intervention should the nurse include in the care plan? Keep the AV fistula site dry. Keep the AV fistula wrapped in gauze. Take the client's blood pressure in the left arm. Assess the AV fistula for a bruit and thrill.
assess AV fistula for a bruit and thrill
A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time? Assess for a cough reflex. Call dietary services to send the client's tray now. Assess for bowel sounds. Perform mouth care.
assess for a cough reflex
Which of the following terms describes the involuntary flapping movements of the hands associated with metabolic liver dysfunction? Asterixis Paracentesis Ascites Dialysis
asterixis
You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? Tetraplegia Areflexia Autonomic dysreflexia Paraplegia
autonomic dysreflexia
An adult client with a history of dyspepsia has been diagnosed with chronic gastritis. The nurse's health education should include what guidelines? Select all that apply. Avoid drinking alcohol Adopt a low-residue diet Avoid nonsteroidal anti-inflammatories Take calcium gluconate as prescribed Prepare for the possibility of surgery
avoid NSAIDs avoid drinking alcohol
To prevent gastroesophageal reflux in a client with hiatal hernia, the nurse should provide which discharge instruction? "Lie down after meals to promote digestion." "Avoid coffee and alcoholic beverages." "Take antacids with meals." "Limit fluid intake with meals."
avoid coffee and alcoholic beverages
A nurse is teaching a client about peritoneal dialysis. The nurse should tell the client the dwell time is: a. 10 minutes b. 20 minutes c. 30 minutes d. 60 minutes
b. 20 minutes
The nurse is caring for a client with acute glomerular inflammation. When assessing for the characteristic signs and symptoms of this health problem, the nurse should include which assessments? Select all that apply. a. Percuss for pain in the right lower abdominal quadrant. b. Assess for the presence of peripheral edema. c. Auscultate the client's apical heart rate for dysrhythmias. d. Assess the client's BP. e. Assess the client's orientation and judgment.
b. Assess for the presence of peripheral edema. d. Assess the client's BP.
Compliance to a renal diet is a difficult lifestyle change for a patient on hemodialysis. The nurse should reinforce nutritional information. Which of the following teaching points should be included? Select all that apply. a. Limit protein to 1.6 g/kg/day. b. Eat foods such as milk, fish, and eggs. c. Restrict sodium to 2,000 to 3,000 mg daily. d. Increase potassium to prevent cardiac problems. e. Restrict fluid to daily urinary output plus 500 to 800 mL.
b. Eat foods such as milk, fish, and eggs. c. Restrict sodium to 2,000 to 3,000 mg daily. e. Restrict fluid to daily urinary output plus 500 to 800 mL.
A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing action? a. administer ARBs b. assess oxygen saturation c. administer diuretics d. administer ACE inhibitors
b. assess oxygen saturation
While auscultating the heart sounds of a client with heart failure, the nurse hears an extra heart sound immediately after the second heart sound (S2). How should the nurse document this sound? a. first heart sound b. third heart sound c. fourth heart sound d. murmur
b. third heaert sound
The nurse knows that women and the elderly are at greater risk for a fatal myocardial event. Which factor is the primary contributor of this cause? a. Chest pain is typical b. Vague symptoms c. Decreased sensation to pain d. Gender bias
b. vague symptoms
A nurse is working with a client being extubated from the ventilator. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? Fluid intake for the past 24 hours Baseline arterial blood gas (ABG) levels Complete blood count results Electrocardiogram (ECG) results
baseline arterial blood gas levels
A nurse expects to note an elevated serum glucose level in a client with hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Which other laboratory finding should the nurse anticipate? Elevated serum acetone level Serum ketone bodies Serum alkalosis Below-normal serum potassium level
below normal serum potassium level
Which of the following clinical manifestations occur in cardiogenic shock? Blood pressure falls Urine output increases Skin is dry Quick capillary refill
blood pressure falls
During preshock, the compensatory stage of shock, the body, through sympathetic nervous system stimulation, will release catecholamines to shunt blood from one organ to another. Which of the following organs will always be protected? Liver Kidneys Lungs Brain
brain
Evaluation of an adult client reveals oversecretion of growth hormone. Which of the following would the nurse expect to find? Excessive urine output Weight loss Bulging forehead Constant thirst
bulging forehead
The nurse is admitting a client with an elevated creatine kinase-MB isoenzyme (CK-MB). What is the cause for the elevated isoenzyme? a. cerebral bleeding b. IM injection c. myocardial necrosis d. skeletal muscle damage due to a recent fall
c. myocardial necrosis
A patient in the recovery room after cardiac surgery begins to have extremity paresthesia, peaked T waves, and mental confusion. What type of electrolyte imbalance does the nurse suspect this patient is having? a. calcium b. magnesium c. potassium d. sodium
c. potassium
Based on her knowledge of the primary cause of end-stage renal disease, the nurse knows to assess the most important indicator. What is that indicator? a. Blood pressure b. Urine protein c. Serum glucose d. pH and HCO3
c. serum glucose
When a client who has been diagnosed with angina pectoris reports experiencing chest pain more frequently, even at rest, that the period of pain is longer, and that it takes less stress for the pain to occur, the nurse recognizes that the client is describing which type of angina? a. Intractable b. Variant c. Unstable d. Refractory
c. unstable
A client undergoes a biopsy of a suspicious lesion. The biopsy report classifies the lesion according to the TNM staging system as follows: Tis, N0, M0. What does this classification mean? No evidence of primary tumor, no abnormal regional lymph nodes, and no evidence of distant metastasis Carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis Can't assess tumor or regional lymph nodes and no evidence of metastasis Carcinoma in situ, no demonstrable metastasis of the regional lymph nodes, and ascending degrees of distant metastasis
carcinoma in situ, no abnormal regional lymph nodes, and no evidence of distant metastasis
When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately? Weight loss of 2 pounds in 3 days Change in the client's handwriting and/or cognitive performance Anorexia for more than 3 days Constipation for more than 2 days
change in client's handwriting and/or cognitive performance
A client with type 1 diabetes reports waking up in the middle of the night feeling nervous and confused, with tremors, sweating, and a feeling of hunger. Morning fasting blood glucose readings have been 110 to 140 mg/dL. The client admits to exercising excessively and skipping meals over the past several weeks. Based on these symptoms, the nurse plans to instruct the client to administer an increased dose of neutral protamine Hagedorn insulin in the evening. check blood glucose at 3:00 a.m. eat a complex carbohydrate snack in the evening before bed. skip the evening neutral protamine Hagedorn insulin dose on days when exercising and skipping meals.
check the blood glucose level at 3 am
A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism? Nonproductive cough and abdominal pain Hypertension and lack of fever Bradypnea and bradycardia Chest pain and dyspnea
chest pain and dyspnea
A client with calculi in the gallbladder is said to have Cholecystitis Cholelithiasis Choledocholithiasis Choledochotomy
cholelithiasis
The nurse is educating a client who is required to restrict potassium intake. What foods would the nurse suggest the client eliminate that are rich in potassium? Butter Citrus fruits Cooked white rice Salad oils
citrus fruits
Which is a true statement regarding hospice care? Clients have a life expectancy of 6 months or less. It is cure-focused. It encourages the prolongation of life through artificial means. Patients have an acute illness.
clients have a life expectancy of 6 months or less
The nurse is explaining the cause of angina pain to a client. What will the nurse say most directly caused the pain? a. incomplete blockage of a major coronary artery b. a destroyed part of the heart muscle c. complete closure of an artery d. a lack of oxygen in the heart muscle cells
d. a lack of oxygen in the heart muscle cells
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? Decerebrate Normal Flaccid Decorticate
decerebrate
A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for: exophthalmos and conjunctival redness. flushed, warm, moist skin. systolic murmur at the left sternal border. decreased body temperature and cold intolerance.
decreased body temperature and cold intolerance
A client with long-standing type 1 diabetes is admitted to the hospital with unstable angina pectoris. After the client's condition stabilizes, the nurse evaluates the diabetes management regimen. The nurse learns that the client sees the physician every 4 weeks, injects insulin after breakfast and dinner, and measures blood glucose before breakfast and at bedtime. Consequently, the nurse should formulate a nursing diagnosis of: Impaired adjustment. Defensive coping. Deficient knowledge (treatment regimen). Health-seeking behaviors (diabetes control).
deficit knowledge (treatment regimen)
A nurse is assessing a client with possible Cushing's syndrome. In a client with Cushing's syndrome, the nurse expects to find: hypotension. thick, coarse skin. deposits of adipose tissue in the trunk and dorsocervical area. weight gain in arms and legs.
deposits of adipose tissue in the trunk and dorsocervical area
During hemodialysis, toxins and wastes in the blood are removed by which of the following? Diffusion Osmosis Ultrafiltration Filtration
diffusion
The client with chronic renal failure is exhibiting signs of anemia. Which is the best nursing rationale for this symptom? Azotemia Diminished erythropoietin production Impaired immunologic response Electrolyte imbalances
diminished erythropoietin production
The nurse reviews dietary guidelines with a client who had a gastric banding. Which teaching points are included? Select all that apply. Eat six meals a day. Limit meal size to 450 to 500 mL. Do not eat and drink at the same time. Drink plenty of water, from 90 minutes after each meal to 15 minutes before each meal. Avoid fruit drinks and soda.
do not eat and drink at the same time avoid fruit drinks and soda drink plenty of water, from 90 min after each meal to 15 min before each meal
A nurse is providing follow-up teaching at a clinic visit for a client recovering from gastric resection. The client reports sweating, diarrhea, nausea, palpitations, and the desire to lie down 15 to 30 minutes after meals. Based on the client's assessment, what will the nurse suspect? Dumping syndrome Dehiscence of the surgical wound Peritonitis A normal reaction to surgery
dumping syndrome
The most common symptom of esophageal disease is nausea. vomiting. dysphagia. odynophagia.
dysphagia
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? Have the patient lie in a supine position during the use of the spirometer. Encourage the patient to try to stop coughing during and after using the spirometer. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. Encourage the patient to take approximately 10 breaths per hour, while awake.
encourage the patient to take approx 10 breaths per hour while awake
Anorexia and cachexia are common problems at the end of life. The nurse plays an important role in managing symptoms and preventing complications. Which of the following are appropriate nursing interventions for these problems? Select all that apply. Advise the patient and family about the importance of a balanced diet. Encourage the patient to eat in an upright position. Suggest a daily weighing time to monitor treatment plan. Recommend that the patient eat when hungry, regardless of usual meal times. Teach the patient how to increase the nutritional value of meals (i.e., add dry milk powder to milk).
encourage the pt to eat in an upright position recommend that the pt eat when hungry, regardless of usual meal times teach the patient how to increase the nutritional value of meals
A patient visits a health clinic because of urticaria and shortness of breath after being stung by several wasps. The nurse practitioner immediately administers which medication to reduce bronchospasm? Epinephrine Benadryl Proventil Prednisone
epinephrine
Which of the following would the nurse most likely assess in a client with diabetes who is experiencing autonomic neuropathy? Skeletal deformities Paresthesias Erectile dysfunction Soft tissue ulceration
erectile dysfunction
A client is being treated for AKI and the client daily weights have been ordered. The nurse notes a weight gain of 3 pounds (1.4 kg) over the past 48 hours. What nursing diagnosis is suggested by this assessment finding? Imbalanced Nutrition: More than body requirements Excess Fluid Volume Sedentary Lifestyle Adult Failure to Thrive
excess fluid volume
Nursing students are reviewing various procedures that can be used to obtain a tissue biopsy of the breast. They demonstrate understanding of the material when they identify which of the following as being done using local anesthesia and intravenous (IV) sedation? Select all that apply. Fine-needle aspiration Excisional biopsy Stereotactic biopsy Wire needle localization Core needle biopsy
excisional biopsy wire needle localization
The mode of transmission of hepatitis A virus (HAV) includes which of the following? Fecal-oral Blood Semen Saliva
fecal-oral
A client diagnosed with breast cancer has developed neutropenia secondary to chemotherapy. Which of the following would the nurse anticipate as being ordered to address the neutropenia? Select all that apply. Filgrastim Epoetin alfa Pegfilgrastim Ondansetron Paclitaxel
filgratism pegfligratism
The nurse is developing a plan of care for a patient with peptic ulcer disease. What nursing interventions should be included in the care plan? Select all that apply. Making neurovascular checks every 4 hours Frequently monitoring hemoglobin and hematocrit levels Observing stools and vomitus for color, consistency, and volume Checking the blood pressure and pulse rate every 15 to 20 minutes Inserting an indwelling catheter for incontinence
frequently monitoring hemoglobin and hematocrit levels observing stools and vomitus for color, consistency, and volume checking the blood pressure and pulse rate every 15-20 minutes
The nurse is caring for a client who has just returned from the PACU after surgery for peptic ulcer disease. For what potential complications does the nurse know to monitor? Select all that apply. Hemorrhage Inability to clear secretions Perforation Penetration Pyloric obstruction Cachexia
hemorrhage perforation penetration pyloric obstruction
A healthcare provider orders several drugs for a client with hemorrhagic stroke. Which drug order should the nurse question? Heparin sodium Dexamethasone Methyldopa Phenytoin
heparin sodium
A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition? Hepatic encephalopathy Portal hypertension Asterixis Cirrhosis
hepatic encephalopathy
A client is diagnosed with polycystic kidney disease. Which symptom would the nurse most likely assess? Hypertension Flank pain Fever Periorbital edema
hypertension
The nurse is assessing a client in the clinic who appears restless, excitable, and agitated. The nurse observes that the client has exophthalmos and neck swelling. What diagnosis do these clinical manifestations correlate with? Hypothyroidism Hyperthyroidism Syndrome of inappropriate antidiuretic hormone secretion (SIADH) Diabetes insipidus (DI)
hyperthyroidism
For the first 72 hours after thyroidectomy surgery, a nurse should assess a client for Chvostek's sign and Trousseau's sign because they indicate: hypocalcemia. hypercalcemia. hypokalemia. hyperkalemia.
hypocalcemia
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? Hypoxia Delirium Hyperventilation Semiconsciousness
hypoxia
A nurse is teaching a client with adrenal insufficiency about corticosteroids. Which statement by the client indicates a need for additional teaching? "I will avoid friends and family members who are sick." "I will eat lots of chicken and dairy products." "I may stop taking this medication when I feel better." "I will see my ophthalmologist regularly for a check-up."
i may stop taking this medication when I feel better
Which of the following would the nurse expect to find when reviewing the laboratory test results of a client with renal failure? Increased serum creatinine level Decreased serum potassium level Increased red blood cell count Increased serum calcium level
increased serum creatinine level
A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant? Decreased level of consciousness (LOC) Elevated blood pressure Increased urine output Decreased heart rate
increased urine output
A nurse is assessing a client who is receiving total parenteral nutrition (TPN). Which finding suggests that the client has developed hyperglycemia? Cheyne-Stokes respirations Increased urine output Decreased appetite Diaphoresis
increased urine output
You are caring for a client in the compensation stage of shock. You know that in this stage of shock adrenaline and noradrenaline are released into the circulation. What positive effect does this have on your client? Increases myocardial contractility Decreases blood return to the heart Decreases carbon dioxide exchange Contracts bronchioles
increases myocardial contractility
A client who sustained a pulmonary contusion in a motor vehicle crash develops a pulmonary embolism. What is the priority nursing concern with this client? Excess fluid volume Acute pain Ineffective breathing pattern Activity intolerance
ineffective breathing pattern
A nursing student is caring for a client with gastritis. Which of the following would the student recognize as a common cause of gastritis? Choose all that apply. Ingestion of strong acids Irritating foods Overuse of aspirin DASH diet Participation in highly competitive sports
ingestion of strong acids irritating foods overuse of aspirin
A client with type 1 diabetes is admitted to an acute care facility with diabetic ketoacidosis. To correct this acute diabetic emergency, which measure should the health care team take first? Initiate fluid replacement therapy. Administer insulin. Correct diabetic ketoacidosis. Determine the cause of diabetic ketoacidosis.
initiate fluid replacement therapy
A client recovering from an acute asthma attack experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: insert a nasogastric tube (NG) as ordered. administer acetaminophen as ordered. instruct the client to breathe into a paper bag. administer antibiotics as ordered.
instruct the client to breathe into a paper bag
Which term refers to the progressive increase in blood glucose from bedtime to morning? Somogyi effect Insulin waning Dawn phenomenon Diabetic ketoacidosis (DKA)
insulin waning
The most common type of goiter is caused by lack of which of the following? Iodine Calcium Potassium Sodium
iodine
The nurse is in the radiology unit of the hospital. The nurse is caring for a client who is scheduled for a lung scan. The nurse knows that lung scans need the use of radioisotopes and a scanning machine. Before the perfusion scan, what must the client be assessed for? Bleeding Iodine allergy Dysrhythmias Inflammation
iodine allergy
A client is scheduled for a cholecystogram for later in the day. What is the nurse's understanding on the diagnostic use of this exam? It visualizes the gallbladder and bile duct. It visualizes the liver and pancreas. It shows the sizes of the abdominal organs and detects any masses. It visualizes the biliary structures and pancreas via endoscopy.
it visualizes the gallbladder and bile duct
A client's renal failure has become chronic. Which signs and symptoms are associated with chronic renal failure? Select all that apply. lethargy muscle cramps bleeding of the oral mucous membranes enhanced cognition
lethargy muscle cramps bleeding of oral mucous membranes
Which of the following would the nurse expect the physician to order for a client with hypothyroidism? Levothyroxine sodium Methimazole Propranolol Propylthiouracil
levothyroxine sodium
A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder? Coagulation studies Magnetic resonance imaging Radioisotope liver scan Liver biopsy
liver biopsy
A client is undergoing a left modified radical mastectomy for breast cancer. Postoperatively, blood pressure should be obtained from the right arm, and the client's left arm and hand should be elevated as much as possible to prevent which condition? Lymphedema Trousseau's sign IV infusion infiltration Muscle atrophy
lymphedema
A nurse is providing dietary instructions to a client with a history of pancreatitis. Which instruction is correct? "Maintain a high-fat diet and drink at least 3 L of fluid a day." "Maintain a high-sodium, high-calorie diet." "Maintain a high-carbohydrate, low-fat diet." "Maintain a high-fat, high-carbohydrate diet."
maintain a high carb, low fat diet
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? Position the client in the supine position Maintain cerebral perfusion pressure from 50 to 70 mm Hg Restrain the client, as indicated Administer enemas, as needed
maintain cerebral perfusion from 50-70 mm Hg
The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? Elevating the head of the bed to 30 degrees Monitoring for seizure activity Administering a stool softener Maintaining a patent airway
maintaining a patent airway
A nurse is providing education to a client with GERD. The client asks what measures can be taken independently to help reduce the symptoms. Which interventions would the nurse recommend? Select all that apply. maintaining an upright position following meals avoiding foods that intensify symptoms sleeping in a supine position ensuring intake of food and fluids 2 to 3 hours before bedtime
maintaining an upright position following meals avoiding foods that intensify symptoms
Which of the following is the nurse's primary concern when providing end-of-life care for a client and the family? Select all that apply. Maintaining client comfort Arranging plans for after death Supporting family members Providing personal care Completing a head-to-toe assessment Encouraging fluids
maintaining client comfort supporting family members providing personal care
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber Keeping the collection chamber at chest level Stripping the chest tube every hour
measuring and documenting the drainage in the collection chamber
The nurse is providing discharge instructions for a slightly overweight client seen in the Emergency Department with gastroesophageal reflux disease (GERD). The nurse notes in the client's record that the client is taking carbidopa/levodopa. Which order for the client by the health care provider should the nurse question? a low-fat diet elevation of upper body on pillows pantoprazole metoclopramide
metoclopramide
Which positioning strategy should be used for a client diagnosed with hypovolemic shock? Supine Modified Trendelenburg Prone Semi-Fowler
modified trendelenburg
A patient arrives in the emergency department with complaints of chest pain radiating to the jaw. What medication does the nurse anticipate administering to reduce pain and anxiety as well as reducing oxygen consumption? Codeine Meperidine Hydromorphone Morphine
morphine
The nurse is caring for a client in the irreversible stage of shock. The nurse is explaining to the client's family the poor prognosis. Which would the nurse be most accurate to explain as the rationale for imminent death? Endotoxins in the system Limited gas exchange Brain death Multiple organ failure
multiple organ failure
A client with a history of depression is brought to the ED after overdosing on Valium. This client is at risk for developing which type of distributive shock? neurogenic shock septic shock anaphylactic shock hypovolemic shock
neurogenic shock
The client is receiving adjuvant chemotherapy for breast cancer. Which is most likely her node status and tumor size? Node negative, tumor size 0.3 cm Node negative, tumor size 0.5 cm Node negative, tumor size 1.2 cm Node negative, tumor size 0.2 cm
node negative, tumor size 1.2 cm
A patient is brought to the emergency department with a possible stroke. What initial diagnostic test for a stroke, usually performed in the emergency department, would the nurse prepare the patient for? 12-lead electrocardiogram Carotid ultrasound study Noncontrast computed tomogram Transcranial Doppler flow study
non contrast CT
A client, aged 75, is diagnosed with a renal disease and administered nephrotoxic drugs in normal doses. The nurse is aware that it is important to observe the client closely for any changes in renal status. Which of the following measures may help a nurse determine a change in renal status? Observing the client's fluid intake. Checking for a thrill or a bruit daily. Observing the client's urinary output. Observing the skin color and nail beds.
observing client's urinary output
Which of the following medications is classified as a proton pump inhibitor (PPI)? Omeprazole Nizatidine Cimetidine Famotidine
omeprazole
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. pH PaCO2 HCO3 Glucose Na+ K+
pH PaCO2 HCO3
When assessing a client's potential for pulmonary emboli, what finding by the nurse indicates possible deep vein thrombosis? Pain in the feet Inability to dorsiflex Negative Homan's sign Pain in the calf
pain in the calf
Cardiac effects of hyperthyroidism include decreased pulse pressure. decreased systolic BP. bradycardia. palpitations.
palpitations
A client admitted to the hospital following a motor vehicle crash has suffered a flail chest. The nurse assesses the client for what most common clinical manifestation of flail chest? Paradoxical chest movement Cyanosis Hypertension Wheezing
paradoxical chest movement
A nurse is caring for a client who is undergoing a diagnostic workup for a suspected gastrointestinal problem. The client reports gnawing epigastric pain following meals and heartburn. What would the nurse suspect this client has? peptic ulcer disease ulcerative colitis appendicitis diverticulitis
peptic ulcer disease
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? pH, 7.5; PaCO2 30 mm Hg pH, 7.40; PaCO2 35 mm Hg pH, 7.35; PaCO2 40 mm Hg pH, 7.25; PaCO2 50 mm Hg
ph 7.25, PaCO2 50
During a follow-up visit to the physician, a client with hyperparathyroidism asks the nurse to explain the physiology of the parathyroid glands. The nurse states that these glands produce parathyroid hormone (PTH). PTH maintains the balance between calcium and: sodium. potassium. magnesium. phosphorus.
phosphorus
A nurse is caring for a client who is suspected to have developed a peptic ulcer hemorrhage. Which action would the nurse perform first? Place the client in a recumbent position with the legs elevated. Prepare a peripheral and central line for intravenous infusion. Assess vital signs. Notify the healthcare provider.
place the client in a recumbent position with the legs elevated
The nurse is caring for a client who has returned to the unit following a bronchoscopy. The client is asking for something to drink. Which criterion will determine when the nurse should allow the client to drink fluids? Presence of a cough and gag reflex Absence of nausea Ability to demonstrate deep inspiration Oxygen saturation of ≥92%
presence of a cough and gag reflex
During chemotherapy, an oncology client has a nursing diagnosis of Impaired oral mucous membrane related to decreased nutrition and immunosuppression secondary to the cytotoxic effects of chemotherapy. Which nursing intervention is most likely to decrease the pain of stomatitis? Recommending that the client discontinue chemotherapy Providing a solution of viscous lidocaine for use as a mouth rinse Monitoring the client's platelet and leukocyte counts Checking regularly for signs and symptoms of stomatitis
providing a solution of viscous lidocaine for use as a mouth rinse
The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to Sit in an upright position only. Initially inhale through the mouth. Purse the lips when exhaling air from the lungs. Hold the breath for 5 seconds and then exhale.
purse the lips when exhaling air from the lungs
Which term refers to the symptom of gastroesophageal reflux disease (GERD), which is characterized by a burning sensation in the esophagus? Pyrosis Dyspepsia Dysphagia Odynophagia
pyrosis
A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level? Cool, moist skin Rapid, thready pulse Arm and leg trembling Slow, shallow respirations
rapid, thready pulse
Erythropoietin growth factor increases production of which of the following? Red blood cells White blood cells Platelets Plasma
red blood cells
A client has been receiving chemotherapy to treat cancer. Which assessment finding suggests that the client has developed stomatitis? White, cottage cheese-like patches on the tongue Yellow tooth discoloration Red, open sores on the oral mucosa Rust-colored sputum
red, open sores on the oral mucosa
The nurse anticipates that a client who is immunosuppressed is at the greatest risk for developing which type of shock? Neurogenic Septic Cardiogenic Anaphylactic
septic
A client with diabetes mellitus has a prescription for 5 units of U-100 regular insulin and 25 units of U-100 isophane insulin suspension (NPH) to be taken before breakfast. At about 4:30 p.m., the client experiences headache, sweating, tremor, pallor, and nervousness. What is the most probable cause of these signs and symptoms? Serum glucose level of 450 mg/dl Serum glucose level of 52 mg/dl Serum calcium level of 8.9 mg/dl Serum calcium level of 10.2 mg/dl
serum glucose level of 52 mg/dl
A client is receiving chemotherapy to treat breast cancer. Which assessment finding indicates a chemotherapy-induced complication? Urine output of 400 ml in 8 hours Serum potassium level of 2.6 mEq/L Blood pressure of 120/64 to 130/72 mm Hg Sodium level of 142 mEq/L
serum potassium level of 2.6 mEq/L
A patient is exhibiting classic signs of a hemorrhagic stroke. What complaint from the patient would be an indicator of this type of stroke? Numbness of an arm or leg Double vision Severe headache Dizziness and tinnitus
severe headache
Which is the most common report by clients with pancreatitis? Tarry, black stools and dark urine Increased and painful urination Increased appetite and weight gain Severe, radiating abdominal pain
severe, radiating abdominal pain
The nurse is providing discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client correctly mentions which early sign of exacerbation? Shortness of breath Weight loss Fever Headache
shortness of breath
The home care nurse is visiting a client newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? Resumption of the client's ADLs The family's willingness to care for the client Nutritional status and fluid balance Signs and symptoms of respiratory complications
signs and symptoms of respiratory complications
A client diagnosed with acute kidney injury (AKI) has a serum potassium level of 6.5 mEq/L. The nurse anticipates administering: sodium polystyrene sulfonate (Kayexalate) Sorbitol IV dextrose 50% Calcium supplements
sodium polystyrene sulfonate (kayexalate)
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? Akathisia Spasticity Ataxia Myoclonus
spasticity
A 15-year-old is admitted to the renal unit with a diagnosis of postinfectious glomerular disease. The nurse should recognize that this form of kidney disease may have been precipitated by what event? Psychosocial stress Hypersensitivity to an immunization Menarche Streptococcal infection
streptococcal infection
Which condition occurs when blood collects between the dura mater and arachnoid membrane? Intracerebral hemorrhage Epidural hematoma Extradural hematoma Subdural hematoma
subdural hematoma
A client is admitted with a gastrointestinal bleed. What client symptom may indicate a peptic ulcer perforation to the nurse? Sudden, severe upper abdominal pain Hypertension Bradycardia Soft abdomen
sudden, severe upper abdominal pain
The nurse is caring for a client receiving hemodialysis three times weekly. The client has had surgery to form an arteriovenous fistula. What is most important for the nurse to be aware of when providing care for this client? Using a stethoscope for auscultating the fistula is contraindicated. The client feels best immediately after the dialysis treatment. Taking a BP reading on the affected arm can damage the fistula. The client should not feel pain during initiation of dialysis.
taking a BP reading on the affectied arm can damage the fistula
A health care provider tells a breast cancer client that he is going to prescribe hormone therapy that has been found to significantly reduce mortality. Which drug would most likely be prescribed? Lapatinib Bevacizumab Tamoxifen Trastuzumab
tamoxifen
The nurse is caring for a patient with hyperthyroidism who suddenly develops symptoms related to thyroid storm. What symptoms does the nurse recognize that are indicative of this emergency? Heart rate of 62 Blood pressure 90/58 mm Hg Oxygen saturation of 96% Temperature of 102ºF
temp of 102
Which instruction should a nurse give to a client with diabetes mellitus when teaching about "sick day rules"? "Don't take your insulin or oral antidiabetic agent if you don't eat." "It's okay for your blood glucose to go above 300 mg/dl while you're sick." "Test your blood glucose every 4 hours." "Follow your regular meal plan, even if you're nauseous."
test your blood glucose every 4 hours
A client with dysphagia is being prepared for discharge. Which outcome indicates that the client is ready for discharge? The client doesn't exhibit rectal tenesmus. The client is free from esophagitis and achalasia. The client reports diminished duodenal inflammation. The client has normal gastric structures.
the client is free from esophagitis and achalasia
A client with gastroesophageal reflux disease (GERD) has a diagnosis of Barrett esophagus with minor cell changes. What principle should be integrated into the client's subsequent care? The client will be monitored closely to detect malignant changes. Liver enzymes must be checked regularly, as H2 receptor antagonists may cause hepatic damage. Small amounts of blood are likely to be present in the stools and are not cause for concern. Antacids may be discontinued when symptoms of heartburn subside.
the client will be monitored closely to detect malignant changes
A client who is to have breast conservation surgery is also to undergo a sentinel lymph node biopsy (SLNB). Which of the following would the nurse include in the client's preoperative teaching plan? The client will most likely be admitted for an overnight stay. The client's urine may have a blue-green discoloration in the first 24 hours. The client has an increased risk for developing lymphedema. The client will need less emotional support because the procedure is less invasive.
the client's urine may have a blue green discoloration in the first 24 hours
A nurse on the renal unit is caring for a client who will soon begin peritoneal dialysis. The family of the client asks for education about the peritoneal dialysis catheter that has been placed in the client's peritoneum. The nurse explains the three sections of the catheter and talks about the two cuffs on the dialysis catheter. What would the nurse explain about the cuffs? Select all that apply. The cuffs are made of Dacron polyester. The cuffs stabilize the catheter. The cuffs prevent the dialysate from leaking. The cuffs provide a barrier against microorganisms. The cuffs absorb dialysate
the cuffs are made of dacron polyester the cuffs stabilize the catheter the cuffs prevent the dialysate from leaking the cuffs provide barrier against microorganisms
The nurse is providing care for a client whose peptic ulcer disease will be treated with a Billroth I procedure (gastroduodenostomy). The nurse should address which of the following topics when providing health education? Select all that apply. The procedure carries a risk for dumping syndrome The client is likely to require long-term total parenteral nutrition (TPN) The client's vagus nerve may be altered The client can resume a usual diet in 3 to 5 weeks Part of the client's stomach and colon will be removed
the procedure carries a risk for dumping syndrome the clients vagus nerve may be altered
A patient is receiving chemotherapy for breast cancer. Her most recent laboratory test results are as follows:Erythrocytes 4,500,000/cu mmHemoglobin 12.0 gm/dLHematocrit 35%Leukocytes 4,600 gm/dLThrombocytes 125,000/cu mmWhich results suggests some evidence of bone marrow suppression? Erythrocyte count Hemoglobin level Leukocyte count Thrombocyte count
thrombocyte count
The nurse is caring for a patient with acute pancreatitis. The patient has an order for an anticholinergic medication. The nurse explains that the patient will be receiving that medication for what reason? To decrease metabolism To depress the central nervous system and increase the pain threshold To reduce gastric and pancreatic secretions To relieve nausea and vomiting
to reduce gastric and pancreatic secretions
Which of the following is the most effective strategy to prevent hepatitis B infection? Vaccine Barrier protection during intercourse Covering open sores Avoid sharing toothbrushes
vaccine
The nurse is caring for a client with chronic gastritis. The nurse monitors the client knowing that this client is at risk for which vitamin deficiency? Vitamin A Vitamin B12 Vitamin C Vitamin E
vitamin B12
A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client reports a headache. reports generalized weakness. sleeps for short periods of time. vomits.
vomits
A nurse is caring for a client receiving chemotherapy. Which nursing action is most appropriate for handling chemotherapeutic agents? Wear disposable gloves and protective clothing. Break needles after the infusion is discontinued. Disconnect I.V. tubing with gloved hands. Throw I.V. tubing in the trash after the infusion is stopped.
wear disposable gloves and protective clothing
A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect? Weight gain, constipation, and lethargy Weight loss, nervousness, and tachycardia Exophthalmos, diarrhea, and cold intolerance Diaphoresis, fever, and decreased sweating
weight loss, nervousness, and tachycardia
A nurse receives her client care assignment. Following the report, she should give priority assessment to the client: with pinkish mucus discharge in the appliance bag 2 days after an ileal conduit. who has a sodium level of 135 mEq/L and a potassium level of 3.7 mEq/L 7 days after a kidney transplant. who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L. who is experiencing mild pain from urolithiasis.
who, following a kidney transplant, has returned from hemodialysis with a sodium level of 110 mEq/L and a potassium level of 2.0 mEq/L.
A nurse is teaching a group of women about the potential benefits of breast self-examination (BSE). The nurse should teach the women that effective BSE is dependent on what factor? Women's knowledge of how their breasts normally look and feel The rapport that exists between the woman and her primary care provider Synchronizing women's routines around BSE with the performance of mammograms Women's knowledge of the pathophysiology of breast cancer
womens knowledge of how their breasts normally look and feel
Health teaching for a patient with diabetes who is prescribed Humulin N, an intermediate NPH insulin, would include which of the following advice? "Your insulin will begin to act in 15 minutes." "You should expect your insulin to reach its peak effectiveness by 12 noon if you take it at 8:00 AM." "You should take your insulin after you eat breakfast and dinner." "Your insulin will last 8 hours, and you will need to take it three times a day."
you should take your insulin after you eat breakfast and dinner
