EAQ Exam 2

The nurse is assessing the client admitted with diabetic ketoacidosis. Which statement made by the client indicates a need for further education on sick day management? A. "I need to stop taking my insulin when I am ill because I am not eating." B. "I will check my urine for ketones when my blood sugar is over 250." C. "I will try and take in Gatorade and water when I am sick." D. "I will continue all my insulin including my lantus when I am sick.

A. "I need to stop taking my insulin when I am ill because I am not eating." Reasoning: The diabetic client's metabolic needs will require the same amount of insulin and sometimes more when in a stressed state, including illness. The client checking the urine for ketones when blood sugar is over 250, drinking water and Gatorade, and continuing insulin indicate that the client has an understanding of the basic sick day rules.

A client is admitted to the emergency room with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which mediation? A. Aspirin B. Midazolam C. Gabapentin D. Alprazolam

A. Aspirin

Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor? A. Troponin B. Myoglobin C. Homocysteine D. Creatine kinase (CK)

A. Troponin

The blood urea nitrogen (BUN)/creatinine ratio of a client is 3. Which condition does the nurse suspect in the client? A. Fluid volume excess B. Obstructive uropathy C. Severe hepatic damage D. GI bleeding

A. Fluid volume excess

A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for myocardial infarction (MI)? Select all that apply A. Obesity B. Hypertension C. Diabetes insipidus D. Asian-American ancestry E. Increased high density lipoprotein (HDL)

A., B.

An older client is diagnosed with left-sided congestive heart failure. Which assessments should the nurse expect to find? Select all that apply A. Dyspnea B. Crackles C. Hacking cough D. Peripheral edema E. Jugular distension

A., B., C.

A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? A. Nervousness and tachycardia B. Erythema toxicum rash and pruritis C. Diaphoresis and altered mental status D. Deep respirations and fruity odor to the breath

D. Deep respirations and fruity odor to the breath

A client arrives at the emergency room complaining of chest pain and dizziness. The client has a history of angina. The primary healthcare provider prescribes an electrocardiogram (ECG) and lab tests. A change in which component of the ECG tracing should the nurse recognize as the client actively having a myocardial infarction (MI)? A. QRS complex B. S-T segment C. P wave D. R wave

B. S-T segment

A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? A. Metabolic acidosis B. Myocardial hypoxia C. Decreased catecholamine secretion D. Increased parasympathetic nervous system stimulation

B. myocardial hypoxia

After reviewing the laboratory reports, the nurse anticipates that the client has renal impairment. Which test reports support the nurse's concern? Select all that apply. A. Serum albumin: 4.7 g/dL B. Serum creatinine: 2.0 mg/dL C. Serum potassium: 5.9 mEq/L D. Serum cholesterol: 120 mg/dL E. Blood urea nitrogen: 32 mg/dL

B., C., E.

What principle of teaching specific to an older adult should the nurse consider when providing instruction to such a client recently diagnosed with diabetes mellitus? A. Knowledge reduces general anxiety B. Capacity to learn decreases with age C. Continued reinforcement is advantageous D. Readiness of the learner precedes instruction

C. Continued reinforcement is advantageous

The nurse is assessing a client experiencing diabetic ketoacidosis (DKA). Which unique response associated with DKA that is not experienced with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client? A. Fluid loss B. Glycosuria C. Kussmaul respirations D. Increased blood glucose levels

C. Kussmaul respirations

The nurse reviews the kidney function blood studies of four clients. Which client may have impaired kidney function? A. Client 1 - Creatinine: 0.1, BUN: 16 B. Client 2 - Creatinine: 0.8, BUN: 18 C. Client 3 - Creatinine: 1.2, BUN: 20 D. Client 4 - Creatinine: 1.9, BUN: 22

D. Client 4 - Creatinine: 1.9, BUN: 22

Metformin 2 g by mouth is prescribed for a client with type 2 diabetes. Each tablet contains 500 mg. How many tablets should the nurse administer? Record your answer using a whole number.

4

The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? A. Intravenous administration of regular insulin B. Administer insulin glargine subcutaneously at hour of sleep C. Maintain nothing prescribed orally (NPO) status D. IV administration of 10% dextrose

A. Intravenous administration of regular insulin

The nurse is preparing a client who is on metformin therapy and is scheduled to undergo renal computed tomography with contrast dye. What does the nurse anticipate the primary healthcare provider to inform the client regarding the procedure? A. "Discontinue metformin 1 day prior to procedure." B. "Discontinue metformin a half-day prior to procedure." C. "Discontinue metformin 3 days following the procedure." D. "Discontinue metformin 7 days following the procedure."

A. "Discontinue metformin 1 day prior to procedure."

A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic? A. INR B. aPTT C. Bleeding time D. Sedimentation rate

A. INR

An 85-year old has a serum potassium level of 6.7 mEq/L. Which nursing action is the priority at this time? A. Monitor for cardiovascular irregularities B. Inquire about changes in bowel patterns C. Assess for leg muscle twitching or weakness D. Assess for signs and symptoms of dehydration

A. Monitor for cardiovascular irregularities

A nurse is caring for a client with a diagnosis of right-sided heart failure. The nurse expects what assignment findings associated with right-sided heart failure? Select all that apply A. Dependent edema B. Swollen hands and fingers C. Collapsed neck veins D. Right Upper Quadrant discomfort E. Oliguria

A., B., D.

Several hours after administering insulin, the nurse is assessing a client for an adverse response to the insulin. Which client responses are indicative of a hypoglycemic reaction? Select all that apply. A. Tremors B. Anorexia C. Confusion D. Glycosuria E. Diaphoresis

A., C., E.

The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. What should the nurse include in the teaching plan? Select all that apply A. The client should obtain a finger stick blood glucose reading before each meal B. The client does not need to follow a diet specific meal until insulin is required C. The teaching plan should include signs and symptoms of hypoglycemia D. The teaching plan does not need to include signs and symptoms of hypoglycemia as the client is not on insulin E. The teaching plan should include sick day rules

A., C., E.

A nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse advise the client to seek immediate medical attention? Select all that apply A. Dyspnea on exertion B. Unexplainable profuse diaphoresis C. Indigestion not relieved by antacids D. Fatigue the day after a rigorous walk E. Acute chest pain after rigorous exercise F. Nonremitting chest pain after three sublingual nitroglycerine tablets

B., C., E., F.

A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply. A. Polyuria B. Jaundice C. Azotemia D. HTN E. Polycythemia

C. Azotemia, D. HTN Azotemia is an increase in nitrogenous waste, particularly urea, in the blood; this is common in end-stage renal disease. Hypertension occurs as a result of fluid and sodium overload and dysfunction of the rennin-angiotensin-aldosterone system. Excessive nephron damage in end-stage renal disease causes oliguria, not polyuria; excessive urination is common in early kidney insufficiency from an inability to concentrate urine. Jaundice is common with biliary obstruction, not end-stage renal disease. Anemia, not polycythemia, occurs because of decreased erythropoietin, decreased red blood cell (RBC) production, and decreased RBC survival time.

A nurse is reviewing the laboratory reports of a client with a diagnosis of end-stage renal disease. Which test result should the nurse anticipate? A. Arterial pH of 7.5 B. Hematocrit of 54% C. Potassium of 6.3 D. Creatinine of 1.2

C. Potassium of 6.3

A nurse teaches a client with chronic renal failure that salt substitutes cannot be used in the diet. What is the rationale for the nurse's instruction? A. A person's body tends to retain fluid when a salt substitute is included in the diet. B. Limiting salt substitutes in the diet prevents a buildup of waste products in the blood. C. Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats. D. A substance in the salt substitute interferes with the transfer of fluid across capillary membranes, resulting in anasarca.

C. Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats.

A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? A. "My ankles are swollen" B. "I am tired at the end of the day" C. "When I eat a large meal, I feel bloated" D. "I have trouble breathing when I walk rapidly"

D. "I have trouble breathing when I walk rapidly"

A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra tablet should be taken before exercise. What is the best response by the nurse? A. "You will need to decrease your exercise" B. "An extra tablet will help your body use glucose correctly" C. "When taking medicine, your diet will not be affected by exercise" D. "No, but you should observe for signs of hypoglycemia while exercising"

D. "No, but you should observe for signs of hypoglycemia while exercising"

A nurse prepares to administer extended-release metformin to an older adult who has asked that it be crushed because it is difficult to swallow. What will prompt the nurse to ask the provider for a different form of metformin? A. This drug has a wax matrix frame that is difficult to crush. B. The drug has an unpleasant taste, which most clients find intolerable if crushed. C. If crushed, this drug irritates mucosal tissue and can cause oral and esophageal ulcer formation. D. Extended-release formulations are designed to be released slowly, and crushing the tablet will prevent this from occurring

D. Extended-release formulations are designed to be released slowly, and crushing the tablet will prevent this from occurring

At 4:30 pm, a client who is receiving NPH insulin every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing? A. Polydipsia B. Ketoacidosis C. Glycogenesis D. Hypoglycemia

D. Hypoglycemia

The healthcare provider prescribes nitroglycerin ointment for a client who was admitted for chest pain and a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? A. "I may experience a headache" B. "Confusion is a common adverse effect" C. "A slow HR is an expected side effect" D. "Increased BP readings may occur initially"

A. "I may experience a headache" The most common side effect of nitroglycerin is a headache. Additional cardiovascular side effects are hypotension, not hypertension; tachycardia, not bradycardia; and dizziness, not confusion.

Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The client asks the nurse how long it should take for the chest pain to subside after nitroglycerin is taken. What should the nurse tell the client? A. 1-3 minutes B. 4-5 seconds C. 30-45 seconds D. 20-45 minutes

A. 1-3 minutes The onset of action of sublingual nitroglycerin tablets is rapid (1 to 3 minutes); duration of action is 30 to 60 minutes. If nitroglycerin is administered intravenously, the onset of action is immediate, and the duration is 3 to 5 minutes. It takes longer than 30 to 45 seconds for sublingual nitroglycerin tablets to have a therapeutic effect. Sustained-release nitroglycerin tablets start to act in 20 to 45 minutes, and the duration of action is 3 to 8 hours.

The nurse is caring for an older client admitted to the hospital with type 2 diabetes. What is important for the nurse to remember about older clients and type 2 diabetes? A. Older adults seldom develop ketoacidosis B. Older adults secrete no endogenous insulin C. Older adults have a lower risk of complications D. Older adults develop a sudden onset of symptoms

A. Older adults seldom develop ketoacidosis Rationale: Lipolysis is not a common response to meeting the metabolic needs of those with type 2 diabetes---ketones are not present to cause ketoacidosis. Adults with type 2 diabetes do secrete endogenous insulin, but secretion is slow and in smaller than adequate amounts.

A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective? A. Pain subsides as a result of arteriole and venous dilation B. Pulse rate increases because the cardiac output has been stimulated. C. Sublingual area tingles because sensory nerves are being triggered. D. Capacity for activity improves as a response to increased collateral circulation

A. Pain subsides as a result of arteriole and venous dilation

A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? A. "I am unable to run a mile now" B. "I wake up at night short of breath" C. "My wife says I snore very loudly" D. "My shoes seem larger lately"

B. "I wake up at night short of breath"

Which instructions will be most beneficial for a diabetic client with renal disease? Select all that apply. A. Recommend that the client drink boiled water B. Suggest the client go for a morning walk C. Instruct the client to check BP regularly D. Contact the PCP before taking ibuprofen E. Encourage the client to undergo a microalbuminuria test yearly

C., D., E.

The laboratory international normalized ratio (INR) results of a client receiving warfarin have been variable. The nurse interviews the client to determine factors contributing to the problem. Which is most important for the nurse to identify? A. Use of analgesics B. Serum glucose level C. Serum potassium levels D. Adherence to the prescribed drug regimen

D. Adherence to the prescribed drug regimen

A client with an intractable infection is receiving vancomycin. Which laboratory test result should the nurse report? A. Hematocrit 45% B. Calcium 9.0 mg/dL C. White Blood Cells 10,000 D. BUN 30

D. BUN 30 Vancomycin is a nephrotoxic medication. An elevated BUN can be an early sign of toxicity. The BUN of a healthy adult is 10 to 20 mg/dL (3.6-7.1 mmol/L).

A client with type 2 diabetes has been receiving insulin in the hospital while being treated for sepsis. The client's infection is resolving and the primary healthcare provider writes a prescription to discontinue the 7:00 AM dose of insulin and to administer glyburide 5 mg twice daily (8:00 AM and 8:00 PM). The nurse on the day shift (8:00 AM to 4:00 PM) administers the glyburide at 8:30 AM. When recording its administration in the client's record, the nurse sees that the insulin had already been administered at 7:00 AM. What initial action should the nurse take? A. Measure the VS B. Notify the PCP C. Assess for signs of ketoacidosis D. Check blood glucose for hypoglycemia

D. Check blood glucose for hypoglycemia Checking blood glucose level for signs of hypoglycemia is a priority because both of these medications can lower the blood sugar. When any medication error is discovered, the first step is assessing the client. Also, before notifying the primary healthcare provider, it is essential to have as much information as possible; the primary healthcare provider will need to know the client's blood sugar. Also, if the blood sugar is low and the client is responsive and alert, the nurse can provide an immediate snack. Not immediately assessing for or not treating symptoms of hypoglycemia delays care of the client. Although measuring the vital signs may be done eventually, it is not the priority because the error was identified before the oral glyburide had time to precipitate an effect. Ketoacidosis is caused by insufficient insulin. The client was given insulin and an antidiabetic drug that will increase endogenous insulin; this combination would most likely precipitate hypoglycemia, not hyperglycemia.

The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is related to heart failure? A. I see spots before my eyes B. I am tired at the end of the day C. I feel bloated when I eat a large meal D. I have trouble breathing when I climb a flight of stairs

D. I have trouble breathing when I climb a flight of stairs

A client is receiving warfarin. The nurse explains the need for careful regulation of dietary intake of vitamin K. What is the rationale for the nurse's teaching? A. Vitamin K promotes platelet aggregation B. Vitamin K promotes ionization of blood calcium C. Vitamin K promotes fibrinogen formation by the liver D. Vitamin K promotes prothrombin formation by the liver

D. Vitamin K promotes prothrombin formation by the liver