Exam 1 part 2
A client who has been taking digoxin for 20 years is hospitalized. The client exhibits signs of dehydration, and laboratory results identify the presence of hypokalemia. The nurse should monitor the client for which clinical finding indicating digoxin toxicity?
Cardiac dysrhythmias
The nurse assesses a client with emphysema. The nurse expects to find which sign of chronic obstructive pulmonary disease (COPD)?
Chest with an increased anteroposterior (AP) diameter
A nurse teaches an elderly client safety tip to prevent falls. Which physiologic change may have occurred in the client?
decreased bone density
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply.
diarrhea, weakness, dysrhythmia
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?
end stage renal failure
A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective?
"I need to drink liquids with some sodium in them
A nurse educates a mother about safety measures for preschoolers. Which statement by the mother indicates the need for further education?
"I should not teach my child how to swim until he or she is much older."
A client is prescribed metformin extended release to control type 2 diabetes mellitus. Which statement made by this client indicates the need for further education?
"I will stop taking metformin for 24 hours before and after having a test involving dye."
A client with a history of severe diarrhea for the past 3 days is admitted for dehydration. The nurse anticipates that which intravenous (IV) solution will be prescribed initially?
0.9% sodium chloride
Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) should be administered in which manner?
1 to 2 L via nasal cannula to keep SaO 2 above 90%
A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO 2 intoxication (CO 2 narcosis), what should the nurse do?
Administer oxygen at a low concentration to maintain respiratory drive
Which of the following concepts would a nurse think has the strongest link to safety? (Select all that apply.)
Communication Quality Regulation Teamwork
A client with chronic obstructive pulmonary disease (COPD) reports a 5-pound (2.3 kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain?
Cor pulmonale
After reviewing the 24-hour urine collection reports of a client with kidney dysfunction, the nurse suspects diabetes mellitus. Which finding supports this suspicion?
Creatinine level: 40 mg/kg/24 hr
A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner
Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively.
A client reports nausea, vomiting, and seeing a yellow light around objects. A diagnosis of hypokalemia is made. Upon a review of the client's prescribed medication list, the nurse determines that what is the likely cause of the clinical findings?
Digoxin (Lanoxin) These are signs of digitalis toxicity, which is more likely to occur in the presence of hypokalemia
The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances?
Extracellular fluid volume (ECV) deficit, hypocalemia, hypokalemia
The nurse is admitting an older adult with left-sided heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse anticipates which of the following orders?
Furosemide (Lasix) 20 mg PO now
When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide?
Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane.
An 18-year-old adolescent who was diagnosed with new-onset type 1 diabetes mellitus has stress and reports not having a menstrual cycle for a long time. Which condition is the adolescent experiencing?
Hypogonadotropic amenorrhea
A 15-year-old adolescent who has type 1 diabetes mellitus is admitted to the pediatric intensive care unit in ketoacidosis with a blood glucose level of 170 mg/dL (9.4 mmol/L). The adolescent has a history of fluctuating blood glucose readings and difficulty adhering to the therapeutic regimen. A continuous insulin infusion is started. What adverse reaction to the infusion is most important for the nurse to monitor?
Hypokalemia- Insulin moves potassium into the cells along with glucose, thus lowering the serum potassium level.
The nurse is implementing measures to reorient a confused client post earthquake and suggests that a family member accompany the client. Which safety consideration is the nurse demonstrating?
Injury prevention for clients
A client with diabetes mellitus is able to discuss in detail the diabetic metabolic process while eating a piece of chocolate cake. What defense mechanism does the nurse identify when evaluating this behavior?
Intellectualization - the avoidance of a painful emotion with the use of a rational explanation that removes the event from any personal significance.
The nurse is caring for a client with diabetes mellitus. What is the primary fluid shift that occurs with this condition?
Intracellular to intravascular because of hyperosmolarity
A client who has been taking spironolactone is admitted to the hospital with hypokalemia. The nurse will assess the client for which clinical findings? Select all that apply
Lethargy Thready, weak pulse Muscle weakness
A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift?
Lethargy and constipation from hypercalcemia
Which of the following communication terms can be applied to this statement: How messages are received and interpreted would include personal states such as mood disturbance, environmental stimuli related to the setting of the communication, and contextual variables?
Metacommunication
When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. Which type of lung sounds will the nurse hear?
Moist rumbling sounds that clear after coughing
What is the primary benefit to classifying errors as either active or latent
More accurate identification of the part of the system needing improvement
A client with diabetes mellitus complains of difficulty seeing. What would the nurse suspect as the causative factor?
Neovascularization of the retina
The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication?
No observable respiratory difficulty or shortness of breath over the last 24 hours
A client is admitted to the hospital with a diagnosis of dehydration and hypokalemia. What is important for the nurse to consider when administering potassium chloride intravenously to this client?
Oliguria is an indication for withholding intravenous (IV) potassium
The nurse is working with a patient who has been complaining of nausea and diarrhea. The nurse suspects dehydration. Which sign does the nurse expect to see?
Positive Trousseau sign
defining characteristic of high reliability organizations (HROs) is sensitivity to operations. Which of the following is a manifestation of this characteristic?
Process anomalies and outliers are quickly identified.
The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB). What is the rationale for the nurse's teaching?
Prolonged exhalation to decrease air trapping
A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during the care
Put the client in a high Fowler position.
The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take?
Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula
Which statement is included in the clinical reasoning communication category?
Relying heavily on analytic reasoning that requires systematically breaking a situation down into parts, examining alternatives, and weighing options
A client is admitted to an emergency unit after a factory explosion. The nurse is obtaining the client's family history and checking for a medical alert bracelet. Which safety consideration is the nurse following
Risk for errors and adverse events
A patient injured in an earthquake today when a wall fell on his legs received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns?
Serum potassium
What is the priority nursing intervention for an older client with diabetes mellitus who presents with a large leg ulcer?
Teaching how to transfer from a bed to chair in the least painful manner
A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client?
The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula
A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon awakening in the morning. What should the nurse suggest to the client?
Use a humidifier in the bedroom
What does a nurse understand by the quality improvement competency, according to Quality and Safety Education (QSEN)?
Using data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems
A client's laboratory report indicates the presence of hypokalemia. For which clinical manifestations associated with hypokalemia should the nurse assess the client? Select all that apply
anorexia and leg cramps
three elements of nursing competency described in the Quality and Safety for Nurses (QSEN) initiative are knowledge, skill and . . . .
attitude
A client with systemic lupus erythematosus is taking prednisone. The nurse anticipates that the steroid may cause hypokalemia. What food will the nurse encourage the client to eat?
broccoli
An older client who lives alone was found unconscious on the floor at home. The client was admitted to the hospital with the diagnoses of a fractured hip, kidney failure, and dehydration. In the 24 hours since admission, the client received 1500 mL of intravenous fluid, and the serum electrolyte value demonstrates hyponatremia. What would the nurse concludes was the element that most likely contributed to the hyponatremia?
fluid intake
The clinical findings of a client with diabetes mellitus show decreased glucose tolerance. Which complication is anticipated in the client?
frequent yeast infections
A woman with type 2 diabetes mellitus continues taking oral tolbutamide during her pregnancy. What type of malformation may the newborn develop?
hypoglycemia
The nurse is caring for a client with a family history of diabetes mellitus. The client has been following a diet regimen recommended by the dietician and walking for 45 minutes daily for the past eight months. How should the nurse document the client's stage based on the transtheoretical model of health behavior change?
maintenance
A client with anorexia nervosa is admitted to the critical care unit following a period of prolonged starvation. What signs or symptoms indicate to the nurse that the client may have hypokalemia? Select all that apply
muscle weakness cardiac dysrhythmias
The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube?
patient experiencing a problem with a pneumothorax
A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which clinical finding supports the nurse's suspicion that the client is developing cor pulmonale
peripheral edema
The nurse is caring for a client with diabetes mellitus who is scheduled to receive an intravenous (IV) administration of 25 units of insulin in 250 mL normal saline. What does the nurse recognize as the only type of insulin that is compatible with intravenous solutions?
regular insulin
A client's laboratory report indicates hyperkalemia. Which responses should the nurse expect the client to exhibit? Select all that apply.
vomiting, muscle weakness, irregular heartbeat