Exam 2 EAQs
A client with an intractable infection is receiving vancomycin. Which laboratory blood test result should the nurse report? A. Hematocrit 45% B. Ca 9.0 C. WBC 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). This hematocrit is expected in a healthy adult; the range is from 40 to 52. The expected range of the WBC count is 5,000 to 10,000 mm 3 (5-10 X 10 9/L) for a healthy adult. This calcium level is within the expected range of 9.0 to 10.5 (2.25-2.75 mmol/L) for a healthy adult
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 Vitamin K promotes the liver's synthesis of prothrombin, an important blood clotting factor, and will reverse the effects of warfarin. Platelet aggregation and fibrinogen formation by the liver are not promoted by vitamin K. Vitamin K does not affect calcium ionization.
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. Nitroglycerin causes vasodilation, increasing the flow of blood and oxygen to the myocardium and reducing anginal pain. An increased pulse rate does not indicate effectiveness; it is a side effect of nitroglycerin. The tingling indicates that the medication is fresh; relief of pain is the only indicator of effectiveness. Nitroglycerin does not promote the formation of new blood vessels.
An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time? A. Monitor for CV irregularities B. Inquire about changes in bowel patterns C. Assess for leg muscle twitching or weakness D. Assess for s/s of dehydration
A. Monitor for CV irregularities Cardiovascular changes are the most severe problems of hyperkalemia and are the most common cause of death from hyperkalemia. Changes in bowel patterns, leg muscle twitching, and weakness are signs of hyperkalemia but are not life threatening. Dehydration may be a cause of hyperkalemia.
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 adults 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 Lipolysis is not a common response to meeting the metabolic needs of those with type 2 diabetes; therefore, ketones are not present in large enough amounts to cause ketoacidosis. Adults with type 2 diabetes do secrete endogenous insulin, but secretion is slow and in smaller than adequate amounts. The incidence of chronic complications depends on the level of glucose control, not developmental level. The onset of type 2 diabetes is usually gradual, whereas in type 1 diabetes, it is sudden and dramatic.
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 Alkalosis B. Myocardial hypoxia C. Decreased catecholamine secretion D. Increased parasympathetic nervous system stimulation
B. Myocardial hypoxia Dysrhythmias are common and result from decreased oxygen to the cells of the myocardium. Myocardial infarction with tissue necrosis results in metabolic acidosis, not metabolic alkalosis. When physical or emotional stress is experienced, such as in an MI, catecholamine secretion increases; this is part of the "fight or flight" mechanism. Increased sympathetic, not parasympathetic, nervous system stimulation may contribute to the development of dysrhythmias.
The nurse is assessing a client experiencing diabetic ketoacidosis (DKA). Which unique response associated with DKA that is not exhibited 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 level
C. Kussmaul respirations Kussmaul respirations occur in diabetic ketoacidosis (DKA) as the body attempts to correct a low pH caused by accumulation of ketones (ketoacidosis). HHNS affects people with type 2 diabetes who still have some insulin production; the insulin prevents the breakdown of fats into ketones. Fluid loss is common to both because an increased blood glucose level ultimately leads to polyuria. Glycosuria is common to both conditions. Hyperglycemia is common to both conditions.
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.
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" Increased shortness of breath is often an indicator of fluid overload in the heart failure client. Being unable to run a mile (1.6 kilometers), snoring loudly, and shoes seeming larger are not as related to heart failure as waking up at night with shortness of breath.
A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment 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 With right-sided heart failure, signs of systemic congestion occur as the right ventricle fails; key features include dependent edema and swollen hands and fingers. Upper right quadrant discomfort is expected with right ventricular failure because venous congestion in the systemic circulation results in hepatomegaly. Jugular venous collapse and oliguria are key features of left-sided heart failure. Left-sided heart failure is associated with decreased cardiac output.
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 Confusion is typically the first sign of a hypoglycemic reaction. Tremors are a sympathetic nervous system response that occurs because circulating glucose in the brain decreases. Diaphoresis is a cholinergic response to hypoglycemia. Hypoglycemia causes hunger, not anorexia. Because blood glucose is low in hypoglycemia, the renal threshold is not exceeded and glycosuria does not occur.
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 The dosage of warfarin is adjusted according to INR results; if the client fails to take the drug as prescribed, test results will not be reliable in monitoring the client's response to therapy. Although some medications can affect the absorption or metabolism of warfarin and should be investigated, this is less likely to be a cause of fluctuations in laboratory values. Serum glucose level and serum potassium levels do not affect the absorption of warfarin.
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 will 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 alternate drinking Gatorade and water throughout the day while ill. D. I will continue all my insulin including my glargine when I am sick.
A. I will stop taking my insulin when I am ill because I am not eating. 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, alternating water and Gatorade intake, and continuing insulin indicate that the client has an understanding of the basic sick day rules. Alternating the intake of water and Gatorade throughout the day provides noncarbohydrate water and fluids containing glucose and electrolytes while reducing the risk of consuming too much sugar.
An older adult 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 distention
A, B, C The left ventricle pumps oxygen-rich blood to the rest of the body. Left-sided heart failure occurs when the left ventricle doesn't pump efficiently. This prevents the body from getting enough oxygen-rich blood. The blood backs up into the lungs instead, which causes a buildup of fluid. Common symptoms may include: dyspnea, shallow respirations, crackles, dry, hacking cough, and frothy, pink-tinged sputum. Right-sided heart failure occurs when the right side of the heart can't perform its job effectively. Common symptoms of right-sided heart failure include peripheral edema, weight gain, and jugular distention.
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 High blood pressure affects normal kidney function. Clients with renal disease must monitor blood pressure, because increased blood pressure can damage the vessel walls of the kidneys, thereby causing kidney damage, leading to kidney failure. Thus clients with renal disease should be encouraged to check their blood pressure regularly. Drugs such as ibuprofen are potent nephrotoxic agents; therefore, the client must be advised to contact the primary healthcare provider before ingestion to avoid further complications. Diabetic clients should undertake a microalbuminuria test yearly to determine the risk of developing end-stage kidney disease. Drinking boiled water may reduce the risk of infections; however, this instruction is less beneficial when compared to the other interventions. Going for a walk will improve the overall health of the client, but it is not a specific intervention that improves kidney function.
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. The slow-release formulary will be compromised and the client will not receive the entire dose if it is chewed or crushed. The capsules are not difficult to crush. Irritation of the mucosal tissue is not the reason the medication should not be crushed; however, this drug should be given with meals to prevent gastrointestinal irritation. Although taste could be a factor, it is not the priority issue.
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.
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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 specific diet until insulin is required C. The teaching plan should include s/s 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 All diabetic clients, regardless of type, should check finger stick blood sugars before each meal and snack. Antidiabetic medications can cause hypoglycemia; therefore, the client needs to be instructed on the symptoms of hypoglycemia. All diabetic clients need to be educated on sick day rules. All diabetic clients should follow the American Diabetes Association diet.
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 The normal range of the blood urea nitrogen (BUN)/creatinine ratio is from 6 to 25. A decrease in the BUN/creatinine ratio indicates fluid volume excess. An increase in the BUN/creatinine ratio indicates obstructive uropathy. A decrease in the levels of blood urea nitrogen (BUN) indicates severe hepatic damage. An increase in the levels of blood urea nitrogen (BUN) indicates gastrointestinal (GI) bleeding.
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." Metformin can react with the iodinated contrast dye that is given for a renal computed tomography (CT) and cause lactic acidosis. Therefore the nurse anticipates an instruction that the client should discontinue the metformin 1 day before the procedure. Stopping the metformin a half-day before the renal CT may not reduce the risk of lactic acidosis. The client is advised to discontinue the metformin for at least 48 hours after the procedure. It is not necessary to discontinue metformin for 3 to 7 days after a renal CT with contrast media.
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.
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? A. Aspirin B. Midazolam C. Gabapentin D. Alprazolam
A. Aspirin Early administration of aspirin in the setting of acute myocardial infarction (MI) has been demonstrated to significantly reduce mortality. Aspirin inhibits the action of platelets, preventing their ability to clump together and form clots. The mechanism of acute coronary syndrome usually is ruptured plaque in one of the coronary arteries with clot formation obstructing blood flow. Prompt administration of an antiplatelet agent, such as aspirin, significantly reduces damage and can be lifesaving, the earlier the better; hence the reason why it is part of emergency management treatment. Gabapentin is an anticonvulsant and is not the drug of choice to relieve the pain associated with an MI. Midazolam HCl is a sedative-hypnotic that is used for its calming effect, but it will not relieve the pain of an MI. Alprazolam is an anxiolytic that is used for its calming effect, but it will not relieve the pain of an MI.
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" Dyspnea on exertion occurs with heart failure because of the heart's inability to meet the oxygen needs of the body. Seeing spots before one's eyes, being tired at the end of the day, and feeling bloated are not specific to heart failure.
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 a myocardial infarction (MI)? Select all that apply. A. Obesity B. HTN C. Diabetes insipidus D. Asian-American ancestry E. Increased HDL
A, B Obesity increases cardiac workload associated with vascular changes that lead to ischemia, which causes an MI. Hypertension damages blood vessels and increases peripheral resistance and cardiac workload, which may lead to an MI. Diabetes mellitus, not insipidus, is a risk factor for an MI. The risk is higher for African-Americans, not Asian-Americans. Increased levels of low-density lipoprotein (LDL), not HDL, increase the risk for heart disease.
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 Warfarin initially is prescribed day by day, based on INR blood test results. This test provides a standard system to interpret prothrombin times. APTT is used to evaluate the effects of heparin, which acts on the intrinsic pathway. Bleeding time is the time required for blood to cease flowing from a small wound; it is not used for warfarin dosage calculation. Sedimentation rate is a test used to determine the presence of inflammation or infection; it does not indicate clotting ability.
The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? A. IV administration of regular insulin B. Administer insulin glargine SQ at hour of sleep C. Maintain NPO status D. IV administration of 10% Dextrose
A. IV administration of regular insulin A client admitted with DKA will have a blood glucose value greater than 250 and blood ketones. Intravenous (IV) administration of regular insulin is needed to rid the body of ketones and regulate blood glucose. Administration of insulin glargine is not going to reverse the ketoacidosis. The client will be allowed fluids to maintain hydration. Administration of 10% dextrose IV will increase the client's blood glucose.
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 Troponin is the biomarker of choice for a myocardial infarction. Troponin, specifically subtypes cardiac-specific troponin T (cTnT) and cardiac-specific troponin I (cTnI), reflects myocardial muscle protein released into circulation soon after injury. Troponin increases as quickly as CK and remains increased for 2 weeks. Although myoglobin is one of the first cardiac markers to increase after a myocardial infarction (MI), it lacks cardiac specificity. Homocysteine is produced when proteins break down, but it is more indicative of cardiovascular disease than a myocardial infarction. CK isoenzyme levels, especially the creatine phosphokinase (MB) subunit, begin to increase in 3 to 6 hours, peak in 12 to 24 hours, and are increased for 48 hours after the occurrence of the infarct. Although reliable in assisting with an early diagnosis of MI, it is not as sensitive or specific as the troponin test.
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. ST segment C. P wave D. R wave
B. ST segment In ECG tracing, the displacement of the S-T segment is caused by an active ischemic injury in the myocardium. The QRS complex, the P wave, and the R wave are not associated with an MI.
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/d E. Blood urea nitrogen: 32 mg/dL
B, C, E Renal impairment is marked by increased serum creatinine concentration, blood urea nitrogen, and potassium ion concentration levels. The normal serum creatinine concentration lies between 0.5 and 1.5 mg/dL (44.2-132.6 µmol/L). A serum creatinine value of 2.0 mg/dL (176.8 µmol/L) indicates renal impairment. The normal concentration of potassium ions in serum ranges from 3.5 to 5 mEq/L (3.5-5 mmol/L). A potassium ion concentration of 5.9 mEq/L(5.9 mmol/L) indicates kidney dysfunction. The normal value of blood urea nitrogen (BUN) lies between 7 and 20 mg/dL (2.45-7.14 mmol/L). A BUN value of 32 mg/dL (11.424 mmol/L) indicates renal impairment. The normal range of serum albumin concentration lies between 3.5 to 5.5 g/dL (5.075-7.975 µmol/L). A cholesterol value less than 200 mg/dL (5.18 mmol/L) is normal.
The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct 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 nitroglycerin tablets
B, C, E, F Unexplainable profuse diaphoresis, indigestion not relieved by antacids, acute chest pain after rigorous exercise, and nonremitting chest pain after three sublingual nitroglycerine tablets are clinical indicators of inadequate oxygen to the heart. The client should be instructed to seek immediate medical intervention. Dyspnea on exertion and fatigue the day after a rigorous walk are expected.
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, D 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.
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 reinforced is advantageous D. Readiness of the learner precedes instruction
C. Continued reinforced is advantageous Neurologic aging causes forgetfulness and a slower response time; repetition increases learning. Continued reinforcement is an example of repetition. The facts that knowledge reduces general anxiety and that the readiness of the learner precedes instruction reflect principles that are applicable to learning regardless of the client's age. Capacity to learn decreases with age.
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. Salt substitutes usually contain potassium, which can lead to hyperkalemia; dysrhythmias are associated with hyperkalemia. Sodium, not salt substitutes, in the diet causes retention of fluid. Salt substitutes do not contain substances that influence blood urea nitrogen (BUN) and creatinine levels; these are the result of protein metabolism. There is no such substance in salt substitutes that interferes with the transfer of fluid across capillary membranes.
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 Clients with end-stage renal disease have impaired potassium excretion, so the nurse should anticipate a potassium level more than the expected range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Clients with end-stage renal disease usually have a serum pH that is less than 7.35 because of metabolic acidosis. A pH of 7.5 that exceeds the expected range of 7.35 to 7.45 is not anticipated because this is alkalosis. Clients with end-stage renal disease have decreased erythropoietin, which leads to decreased red blood cell production and hematocrit; a hematocrit of 54% exceeds the expected range, which is 39% to 50% for males and 35% to 47% for females; therefore, it is not anticipated. Clients with end-stage renal disease have a decreased ability to eliminate nitrogenous wastes, which leads to increased creatinine levels; a creatinine level of 1.2 mg/dL (106 mcmol/L) is within the expected range of 0.7 to 1.4 mg /dL (62 to 124 mcmol/L) and therefore is not anticipated.
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'm tired by the end of the day" C. "When I ear a large meal, I feel bloated" D. "I have trouble breathing when I walk rapidly"
D. "I have trouble breathing when I walk rapidly" Dyspnea on exertion often occurs with left ventricular heart failure because the heart is unable to pump enough oxygenated blood to meet the energy requirements for muscle contractions related to the activity. The statement "My ankles are swollen" is more likely with right ventricular heart failure. The statement "I am tired at the end of the day" is not specific to left ventricular heart failure. The statement "When I eat a large meal, I feel bloated" is not specific to left ventricular heart failure.
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" Exercise improves glucose metabolism; with exercise there is a risk of developing hypoglycemia, not hyperglycemia. Exercise should not be decreased because it improves glucose metabolism. An extra tablet probably will result in hypoglycemia because exercise alone improves glucose metabolism. Control of glucose metabolism is achieved through a balance of diet, exercise, and pharmacologic therapy.
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.
A nurse is assessing a client and suspects DKA. What clinical findings support this conclusion? A. Nervousness and tachycardia B. Erythema toxicum rash and pruritus C. Diaphoresis and AMS D. Deep respirations and fruity odor to the breath
D. Deep respirations and fruity odor to the breath Deep respirations and a fruity odor to the breath are classic signs of DKA, because of the respiratory system's attempt to compensate by blowing off excess carbon dioxide, a component of carbonic acid. Nervousness and tachycardia are indicative of an insulin reaction (diabetic hypoglycemia). When the blood glucose level decreases, the sympathetic nervous system is stimulated, resulting in an increase in epinephrine and norepinephrine; this causes clinical findings such as nervousness, tachycardia, palpitations, sweating, tremors, and hunger. Erythema toxicum rash and pruritus are unrelated to diabetes; they indicate a hypersensitivity reaction. Although an altered mental state is associated with both hypoglycemia and DKA, diaphoresis is associated only with hypoglycemia. Diaphoresis occurs when the blood glucose level decreases and stimulates an increase in epinephrine and norepinephrine.
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 time of the client's response corresponds to the expected peak action (4 to 12 hours after administration) of the intermediate-acting insulin that was administered in the morning; this can result in hypoglycemia. Hypoglycemia triggers the sympathetic nervous system; epinephrine causes diaphoresis and nervousness. Osmotic diuresis causes thirst; this is related to hyperglycemia, not to hypoglycemia. Warm, dry, flushed skin and lethargy are associated with ketoacidosis. Glycogenesis, the formation of glycogen in the liver, is unrelated to nervousness and cool, moist skin.