Exam 2 test question bank

A nurse is planning care for a client who has Cushing's disease. The nurse should identify that clients who have Cushing's disease are at increased risk for which of the following? (Select all that apply.) A. Infection B. Gastric ulcer C. Renal calculi D. Bone fractures E. Dysphagia

A, B, D A. Infection B. Gastric ulcer D. Bone fractures A. CORRECT: Suppression of the immune system places the client at risk for infection. B. CORRECT: The overproduction of cortisol inhibits the production of a protective mucus lining in the stomach and causes an increase in the amount of gastric acid. These factors place clients who have Cushing's disease at increased risk for gastric ulcers. D. CORRECT: Clients who have Cushing's disease are at risk for bone fractures because decreased calcium absorption leads to osteoporosis.

A nurse is preparing to receive a client from the PACU who is postoperative following a thyroidectomy. The nurse should ensure that which of the following equipment is available? (Select all that apply.) A. Suction equipment B. Humidified oxygen C. Flashlight D. Tracheostomy tray E. Chest tube tray

A, B, D A. Suction equipment B. Humidified oxygen D. Tracheostomy tray A. CORRECT: The client can require oral or tracheal suctioning. Ensure that suctioning equipment is available. B. CORRECT: The client can require supplemental oxygen due to respiratory complications. Humidified oxygen thins secretions and promotes respiratory exchange. This equipment should be available. D. CORRECT: The client can experience respiratory obstruction. A tracheostomy tray should be available at the bedside.

Which new symptoms in a client who is being managed for sickle cell crisis does the nurse report immediately to prevent harm? Select all that apply. A. Decreased handgrip strength on one side B. Diffuse abdominal pain C. Fever of 102.2°F (39°C) D. Increased urine output E. Shortness of breath F. Sore throat

A, C, E A. Decreased handgrip strength on one side C. Fever of 102.2°F (39°C) E. Shortness of breath

With which types of anemia does the nurse ask the client about the presence of the disorder in other family members? Select all that apply. A. Sickle cell anemia B. Folic acid deficiency anemia C. Glucose-6-phosphate dehydrogenase deficiency anemia D. Iron deficiency anemia E. Pernicious anemia F. Vitamin B12 deficiency anemia

A, C, E A. Sickle cell anemia C. Glucose-6-phosphate dehydrogenase deficiency anemia E. Pernicious anemia

A nurse is caring for a client who is receiving a blood transfusion. Which of the following actions should the nurse plan to take if an allergic transfusion reaction is suspected? (Select all that apply.) A. Stop the transfusion. B. Monitor for hypertension. C. Maintain an IV infusion with 0.9% sodium chloride. D. Position the client in an upright position with the feet lower than the heart. E. Administer diphenhydramine.

A, C, E A. Stop the transfusion. C. Maintain an IV infusion with 0.9% sodium chloride. E. Administer diphenhydramine. A. CORRECT: Immediately stop the infusion if an allergic transfusion reaction is suspected. C. CORRECT: Administer 0.9% sodium chloride solution through new IV tubing if an allergic transfusion reaction is suspected. E. CORRECT: Administer an antihistamine, such as diphenhydramine, if an allergic transfusion reaction is suspected.

A nurse is teaching a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include? (Select all that apply.) A. "Avoid taking herbal supplements while taking this medication." B. "Monitor for the presence of black, tarry stools." C. "Take this medication when you have pain." D. "Schedule a weekly PT test." E. "Limit food sources containing vitamin K while taking this medication."

A,B A. "Avoid taking herbal supplements while taking this medication." B. "Monitor for the presence of black, tarry stools." A. CORRECT: Instruct the client to avoid herbal supplements while taking clopidogrel. Herbal supplements (garlic, ginger, ginkgo, ginseng) can increase the risk of bleeding. B. CORRECT: Instruct the client to monitor for evidence of GI bleeding (abdominal pain; coffee-ground emesis; black, tarry stools). If this occurs, the client should report this to the provider.

A nurse is providing discharge teaching to a client who had a gastrectomy for stomach cancer. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. "You will need a monthly injection of vitamin B12 for the rest of your life." B. "Using the nasal spray form of vitamin B12 on a daily basis can be an option." C. "An oral supplement of vitamin B12 taken on a daily basis can be an option." D. "You should increase your intake of animal proteins, legumes, and dairy products to increase vitamin B12 in your diet." E. "Add soy milk fortified with vitamin B12 to your diet to decrease the risk of pernicious anemia."

A,B A. "You will need a monthly injection of vitamin B12 for the rest of your life." B. "Using the nasal spray form of vitamin B12 on a daily basis can be an option." A. CORRECT: The client who had a gastrectomy will require monthly injections of vitamin B12 for the rest of their life due to lack of intrinsic factor being produced by the parietal cells of the stomach. B. CORRECT: Cyanocobalamin nasal spray used daily is an option for a client who had a gastrectomy.

A nurse is caring for a client who has disseminated intravascular coagulation (DIC). Which of the following laboratory values indicates the client's clotting factors are depleted? (Select all that apply.) A. Platelets 100,000/mm B. Fibrinogen levels 120 mg/dL C. Fibrin degradation products 4.3 mcg/mL D. D-dimer 0.03 mcg/mL E. Sedimentation rate 38 mm/hr

A,B A. Platelets 100,000/mm B. Fibrinogen levels 120 mg/dL A. CORRECT: In DIC, platelet levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage. B. CORRECT: In DIC, fibrinogen levels are decreased, causing clotting factors to become depleted. Clotting times are increased, which raises the risk for fatal hemorrhage.

A nurse is reviewing the health history of a client who has diabetes mellitus type 2. Which of the following are risk factors for hyperglycemic hyperosmolar state (HHS)? (Select all that apply.) A. Evidence of recent myocardial infarction B. BUN 35 mg/dL C. Takes a calcium channel blocker D. Age 77 years E. Daily insulin injections

A,B,C,D A. Evidence of recent myocardial infarction B. BUN 35 mg/dL C. Takes a calcium channel blocker D. Age 77 years A. CORRECT: The client who has type 2 diabetes mellitus and had a myocardial infarction is at risk for developing HHS. This is due to the increased hormone production during illness or stress, which can stimulate the liver to produce glucose and decrease the effects of insulin. B. CORRECT: The client who has type 2 diabetes mellitus can be at risk for developing HHS when the BUN is 35 mg/dL because it is an indication of decreased kidney function and inability of the kidney to filter high levels of blood glucose into the urine. C. CORRECT: A calcium channel blocker is one of several medications that increase the risk for HHS in a client who has type 2 diabetes mellitus. D. CORRECT: The older adult client is at risk for developing type 2 diabetes mellitus and can be unaware of associated manifestations, increasing the risk for HHS.

A nurse in an intensive care unit is planning care for a client who has myxedema coma. Which of the following actions should the nurse include? (Select all that apply.) A. Observe cardiac monitor for dysrhythmias. B. Observe for evidence of urinary tract infection. C. Initiate IV fluids using 0.9% sodium chloride. D. Administer a levothyroxine IV bolus. E. Provide warmth using a heating pad.

A,B,C,D A. Observe cardiac monitor for dysrhythmias. B. Observe for evidence of urinary tract infection. C. Initiate IV fluids using 0.9% sodium chloride. D. Administer a levothyroxine IV bolus. A. CORRECT: A client who has myxedema can have a flat or inverted T wave as well as ST deviations. B. CORRECT: An infection (in the urinary tract) can precipitate myxedema coma. Observe the client for manifestations of infection so that the underlying illness can be treated. C. CORRECT: Hyponatremia is an expected finding in the presence of myxedema coma. IV therapy is administered using 0.9% sodium chloride. D. CORRECT: Myxedema coma is a severe complication of hypothyroidism that if left untreated can lead to coma or death. Levothyroxine is administered IV bolus to treat the condition.

A nurse is collecting an admission history from a client who has hypothyroidism. Which of the following findings should the nurse expect? (Select all that apply.) A. Diarrhea В. Menorrhagia C. Dry skin D. Increased libido E. Hoarseness

B,C,E В. Menorrhagia C. Dry skin E. Hoarseness B. CORRECT: Abnormal menstrual periods, including menorrhagia and amenorrhea, are manifestations of hypothyroidism. C. CORRECT: Dry skin is a manifestation of hypothyroidism. E. CORRECT: Hoarseness is a manifestation of hypothyroidism.

A nurse is reviewing laboratory results for a client who has Addison's disease. Which of the following laboratory results should the nurse expect for this client? (Select all that apply.) А. Sodium 130 mEq/L B. Potassium 6.1 mEq/L C. Calcium 11.6 mg/dL D. Blood urea nitrogen (BUN) 28 mg/dL E. Fasting blood glucose 148 mg/dL

A,B,C,D А. Sodium 130 mEq/L B. Potassium 6.1 mEq/L C. Calcium 11.6 mg/dL D. Blood urea nitrogen (BUN) 28 mg/dL A. CORRECT: This finding is below the expected reference range. In the presence of Addison's disease, insufficient glucose can cause sodium and water excretion. Hyponatremia is an expected finding. B. CORRECT: This finding is above the expected reference range. Hyperkalemia is an expected finding for a client who has Addison's disease. C. CORRECT: This finding is above the expected reference range. Hypercalcemia is an expected finding for a client who has Addison's disease. D. CORRECT: This BUN level is above the expected reference range, which is an expected finding for a client who has Addison's disease due to dehydration.

A nurse is providing discharge teaching to a client who had diabetic ketoacidosis. Which of the following information should the nurse include about preventing DKA? (Select all that apply.) A. Drink 2 L fluids daily. B. Monitor blood glucose every 4 hr when ill. C. Administer insulin as prescribed when ill. D. Notify the provider when blood glucose is 200 mg/dL. E. Report ketones in the urine after 24 hr of illness.

A,B,C,E A. Drink 2 L fluids daily. B. Monitor blood glucose every 4 hr when ill. C. Administer insulin as prescribed when ill. E. Report ketones in the urine after 24 hr of illness. A. CORRECT: Drinking 2 L fluids daily can prevent dehydration if the client develops diabetic ketoacidosis. B. CORRECT: Blood glucose tends to increase during illness. Blood glucose should be monitored every 4 hr. C. CORRECT: Illness often causes blood glucose to increase. Regular doses of insulin should be administered. E. CORRECT: The provider should be notified if there are ketones in the urine after 24 hr of illness.

A nurse is reviewing the laboratory findings of a client who has Cushing's disease. Which of the following findings should the nurse expect for this client? (Select all that apply.) A. Sodium 150 mEq/L B. Potassium 3.3 mEq/L С. Calcium 8.0 mg/dL D. Lymphocyte count 35% E. Fasting glucose 145 mg/dL

A,B,C,E A. Sodium 150 mEq/L B. Potassium 3.3 mEq/L С. Calcium 8.0 mg/dL E. Fasting glucose 145 mg/dL A. CORRECT: This finding is above the expected reference range. Hypernatremia is an expected finding for clients who have Cushing's disease. B. CORRECT: This finding is below the expected reference range. Hypokalemia is an expected finding for clients who have Cushing's disease. C. CORRECT: This finding is below the expected reference range. Hypocalcemia is an expected finding for clients who have Cushing's disease. E. CORRECT: This finding is above the expected reference range. Clients who have Cushing's disease have an elevated fasting blood glucose because the disorder affects glucose metabolism.

A nurse in a provider's office is planning care for a client who has a new diagnosis of Graves' disease and a new prescription for methimazole. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Monitor CBC. B. Monitor triiodothyronine (13). C. Instruct the client to increase consumption of shellfish. D. Advise the client to take the medication at the same time every day. E. Inform the client that an adverse effect of this medication is iodine toxicity.

A,B,D A. Monitor CBC. B. Monitor triiodothyronine (13). D. Advise the client to take the medication at the same time every day. A. CORRECT: Methimazole can cause a number of hematologic effects, including leukopenia and thrombocytopenia. Monitor CBC. B. CORRECT: Methimazole reduces thyroid hormone production. Monitor T3. D. CORRECT: Methimazole should be taken at the same time every day to maintain blood levels.

A nurse is planning care for a client who has Hgb 7.5 g/dL and Hct 21.5%. Which of the following actions should the nurse include in the plan of care? (Select all that apply.) A. Provide assistance with ambulation. B. Monitor oxygen saturation. C. Weigh the client weekly. D. Obtain stool specimen for occult blood. E. Schedule daily rest periods.

A,B,D,E A. Provide assistance with ambulation. B. Monitor oxygen saturation. D. Obtain stool specimen for occult blood. E. Schedule daily rest periods. A. CORRECT: Assist the client when ambulating to prevent a fall because the client who has anemia can experience dizziness. B. CORRECT: Monitor oxygen saturation when the client has anemia due to the decreased oxygen-carrying capacity of the blood D. CORRECT: Obtain the client's stool to test for occult blood, which can identify a possible cause of anemia caused from gastrointestinal bleeding. E. CORRECT: Schedule the client to rest throughout the day because the client who has anemia can experience fatigue. Rest periods should be planned to conserve energy.

The health care provider diagnoses the client with acute sickle cell crisis. Four days later, the client is preparing for discharge. Which teaching point will the nurse provide? (Select all that apply.) A. Be sure to get a flu shot annually. B. Drink at least 3 to 4 L of fluid daily. C. Alcoholic beverages may be consumed moderately. D. Get genetic testing to prevent passing this disease to children. E. Engage in mild low-impact exercise three times weekly when not in crisis.

A,B,E A. Be sure to get a flu shot annually. B. Drink at least 3 to 4 L of fluid daily. E. Engage in mild low-impact exercise three times weekly when not in crisis.

A nurse is caring for a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following findings should the nurse expect? (Select all that apply.) A. Decreased blood sodium B. Urine specific gravity 1.001 C. Blood osmolarity 230 mOsm/L D. Polyuria E. Increased thirst

A,C A. Decreased blood sodium C. Blood osmolarity 230 mOsm/L A. CORRECT: An increase in the secretion of ADH leads to dilutional hyponatremia. C. CORRECT: A decrease in blood osmolarity is caused by an increase in the secretion of ADH leading to water retention and dilution of blood components.

A nurse is reviewing the health record of a client who has syndrome of inappropriate antidiuretic hormone (SIADH). Which of the following laboratory findings should the nurse expect? (Select all that apply.) A. Low sodium B. High potassium C. Increased urine osmolality D. High urine sodium E. Increased urine specific gravity

A,C,D,E A. Low sodium C. Increased urine osmolality D. High urine sodium E. Increased urine specific gravity A. CORRECT: SIADH results in water retention, causing a low sodium level. C. CORRECT: SIADH results in an increase in urine osmolality due to the decreased urine volume. D. CORRECT: SIADH results in water retention, causing a high urine sodium level. E. CORRECT: SIADH results in water retention, causing an increase in urine specific gravity.

Two days later the client is recovered and is preparing for discharge. His partner asks what they can do to prevent this from happening again in the future. What teaching will the nurse provide? (Select all that apply.) A. Monitor glucose whenever the client is ill. B. Decrease fluid intake when nausea and vomiting OccUr. C. Watch for and report any illness lasting more than 1 to 2 days. D. Check blood glucose levels every 4 to 6 hours if anorexia, nausea, or vomiting is experienced. E. Check urine ketones when blood glucose is greater than 300 mg/dL.

A,C,D,E A. Monitor glucose whenever the client is ill. C. Watch for and report any illness lasting more than 1 to 2 days. D. Check blood glucose levels every 4 to 6 hours if anorexia, nausea, or vomiting is experienced. E. Check urine ketones when blood glucose is greater than 300 mg/dL.

A client who is 5 weeks postransplant after an allogeneic stem cell transplantation for acute lymphocytic leukemia comes to the clinic with a swollen belly and weight gain. Which additional assessment data support the nurses suspicion of possible sinusoidal obstructive syndrome (SOS)? Select all that apply. A. Jaundiced skin and sclera B. Platelet count is 28,000/mm C. Skin peeling on the hands and feet D. Mixed chimerism by laboratory finding E. Body temperature slightly below normal F. Pain in the upper right abdominal quadrant

A,F A. Jaundiced skin and sclera F. Pain in the upper right abdominal quadrant

The nurse is caring for a 25-year-old client with a history of sickle cell disease (SCD). Today the client reports pain that is rated as a "9" on a 0-to-10 scale. Nursing assessment reveals grimacing, abdominal guarding, fever of 103.9° F, pale yellow hard palate, and several very small ulcers on the lower extremities. 1. Which concern will the nurse address as the priority? A. Acute pain B. Hyperthermia С. Potential for infection D. Impaired tissue perfusion

A. Acute pain

In the ED, the client is diagnosed with diabetic ketoacidosis (DKA). What is the nurse's first priority for managing this condition? A. Airway assessment B. Administration of insulin C. Fluid and electrolyte correction D. Administration of IV potassium

A. Airway assessment

A nurse is caring for a client who has a prescription for an afterload-reducing medication. The nurse should identify that this medication is administered for which of the following types of shock? A. Cardiogenic B. Obstructive C. Hypovolemic D. Distributive

A. Cardiogenic A. CORRECT: Identify that a prescription to reduce afterload will allow the heart to pump more effectively, which is needed for the client who has cardiogenic shock.

Which action best exemplifies the expected outcome of appropriate negative feedback control over endocrine gland hormone secretion? A. Decreased secretion of glucagon when blood glucose approaches normal levels B. Increased secretion of parathyroid hormone in response to a calcium-con-taining intravenous infusion C. Increased secretion of thyroid-stimulating hormone in response to long-term exogenous thyroid hormone replacement therapy D. Decreased secretion of cortisol in response to a pituitary tumor stimulating the increased secretion of adrenocorticotropic hormone

A. Decreased secretion of glucagon when blood glucose approaches normal levels

Which physiological processes directly prevent severe hypoglycemia in a healthy adult without diabetes who is NPO for 12 hours? Select all that apply. A. Gluconeogenesist B. Glycogenesis C. Glycogenolysis D. Ketogenesis E. Lipogenesis F. Lipolysis

A. Gluconeogenesist C. Glycogenolysis

A nurse is caring for a client who has DIC. Which of the following medications should the nurse anticipate administering? A. Heparin B. Vitamin K C. Mefoxin D. Simvastatin

A. Heparin A. CORRECT: Heparin can be administered to decrease the formation of microclots, which deplete clotting factors.

A nurse is providing discharge teaching for a client who has a prescription for furosemide 40 mg PO daily. The nurse should instruct the client to take this medication at which of the following times of day? A. Morning B. Immediately after lunch C. Immediately before dinner D. Bedtime

A. Morning A. CORRECT: The client should take furosemide, a diuretic, in the morning so that the peak action and duration of the medication occurs during waking hours.

A nurse is caring for a client who has primary adrenal insufficiency and is preparing to undergo an ACTH stimulation test. Which of the following findings should the nurse expect after an IV injection of cosyntropin? A. No change in plasma cortisol B. Elevated fasting blood glucose C. Decrease in sodium D. Increase in urinary output

A. No change in plasma cortisol A. CORRECT: No change in plasma cortisol indicates primary adrenal insufficiency (Addison's disease or hypocortisolism) after an IV injection of cosyntropin during an ACTH stimulation test due to an inadequate production of cortisol.

Which precaution is a priority for the nurse to teach a client prescribed sema- glutide to prevent harm? A. Only take this drug once weekly. B. Report any vision changes immediately. C. Do not mix in the same syringe with insulin. D. This drug can only be given by a health care professional.

A. Only take this drug once weekly.

At the beginning of a shift, a nurse is assessing a client who has Cushing's disease. Which of the following findings is the priority? A. Weight gain B. Fatigue C. Fragile skin D. Joint pain

A. Weight gain A. CORRECT: The greatest risk to a client who has Cushing's disease is fluid retention, which can lead to pulmonary edema, hypertension, and heart failure; therefore, this is the priority finding.

A 29-year-old client with type 1 diabetes is admitted to the ED with nausea and abdominal pain. His respiratory rate is 34/min with deep breaths and a fruity smell to his breath. He is responsive, but difficult to arouse. 1. What does the nurse suspect is happening with this client? 2. What serum glucose level would the nurse expect to see with this client?

ANS: 1. The symptoms are consistent with diabetic ketoacidosis (DKA). 2. The client's glucose level is likely >300 mg/dL

A nurse is screening a client for hypertension. The nurse should identify that which of the following actions by the client increase the risk for hypertension? (Select all that apply.) A. Drinking 8 oz nonfat milk daily B. Eating popcorn at the movie theater C. Walking 1 mile daily at 12 min/mile pace D. Consuming 36 oz beer daily E. Getting a massage once a week

B,D B. Eating popcorn at the movie theater D. Consuming 36 oz beer daily B. CORRECT: Popcorn at a movie theater contains a large quantity of sodium and fat, which increases the risk for hypertension. D. CORRECT: Consuming more than 24 oz beer per day for a male client or 12 oz for a female client increases the risk for hypertension.

A nurse is presenting information to a group of clients about nutrition habits that prevent type 2 diabetes mellitus. Which of the following should the nurse include in the information? (Select all that apply.) A. Eat at regular intervals. B. Decrease intake of saturated fats. C. Increase daily fiber intake. D. Limit saturated fat intake to 15% of daily caloric intake. E. Include omega-3 fatty acids in the diet.

ANSWER: A, B, C, E A. Eat at regular intervals. B. Decrease intake of saturated fats. C. Increase daily fiber intake. E. Include omega-3 fatty acids in the diet. A. CORRECT: The client should eat at regular intervals throughout the day to maintain blood glucose levels. B. CORRECT: Healthy nutrition should include lowering LDL by decreasing intake of saturated fats, which can prevent diabetes and hyperlipidemia. C. CORRECT: Healthy nutrition should include increasing dietary fiber to control weight gain and decrease the risk of diabetes and hyperlipidemia. E. CORRECT: Healthy nutrition should include omega-3 fatty acids for secondary prevention of diabetes and heart disease.

A nurse is teaching foot care to a client who has diabetes mellitus. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Remove calluses using over-the-counter remedies. B. Apply lotion between toes. C. Test water temperature with the fingers before bathing. D. Trim toenails straight across. E. Wear closed-toe shoes.

ANSWER: D, E D. Trim toenails straight across. E. Wear closed-toe shoes. D. CORRECT: Trim toenails straight across to prevent injury to soft tissue of the toes. E. CORRECT: Wear closed-toe shoes to prevent injury to soft tissue of the toes and feet.

Which hormones help prevent hypoglycemia? Select all that apply. A. Aldosterone B. Cortisol C. Epinephrine D. Growth hormone E. Glucagon F. Insulin G. Norepinephrine H. Proinsulin

Answers: B, C, D, E, G B. Cortisol C. Epinephrine D. Growth hormone E. Glucagon G. Norepinephrine

A nurse is assessing a client who has diabetic ketoacidosis and ketones in the urine. The nurse should expect which of the following findings? (Select all that apply.) A. Weight gain B. Fruity odor of breath C. Abdominal pain D. Kussmaul respirations E. Metabolic acidosis

B, C, D, E B. Fruity odor of breath C. Abdominal pain D. Kussmaul respirations E. Metabolic acidosis B. CORRECT: Fruity odor of breath is a manifestation of elevated ketone levels that lead to metabolic acidosis. C. CORRECT: Abdominal pain is a GI manifestation of increased ketones and acidosis. D. CORRECT: Kussmaul respirations are an attempt to excrete carbon dioxide and acid when in metabolic acidosis. E. CORRECT: Metabolic acidosis is caused by glucose, protein, and fat breakdown, which produces ketones.

A nurse is admitting a client who has acute adrenal insufficiency. Which of the following prescriptions should the nurse expect? (Select all that apply.) A. IV therapy with 0.45% sodium chloride B. Regular insulin C. Hydrocortisone sodium succinate D. Sodium polystyrene sulfonate E. Furosemide

B, C, D, E B. Regular insulin C. Hydrocortisone sodium succinate D. Sodium polystyrene sulfonate E. Furosemide B. CORRECT: Clients who have acute adrenal insufficiency are hyperkalemic. Insulin is administered to shift potassium into the cells. C. CORRECT: Hydrocortisone sodium succinate is administered as replacement therapy of both glucocorticoid and mineralocorticoid. D. CORRECT: Clients who have acute adrenal insufficiency are hyperkalemic. Sodium polystyrene sulfonate is administered because it absorbs potassium. E. CORRECT: Loop and thiazide diuretics promote potassium excretion and are administered to treat hyperkalemia.

A nurse in the emergency department is completing an assessment on a client who is in shock. Which of the following findings should the nurse expect? (Select all that apply.) A. Heart rate 60/min B. Seizure activity C. Respiratory rate 42/min D. Increased urine output E. Weak, thready pulse

B, C, E B. Seizure activity C. Respiratory rate 42/min E. Weak, thready pulse B. CORRECT: Seizure activity caused by progressive hypoxia can be present in a client who is in shock. C. CORRECT: Tachypnea is an expected finding in a client who is in shock due to the body's attempt to increase oxygen intake. E. CORRECT: A weak, thready pulse caused by low fluid volume, vasoconstriction, and hypotension is an expected finding in a client who is in shock.

A nurse is reviewing the manifestations of hyperthyroidism with a client. Which of the following findings should the nurse include? (Select all that apply.) A. Anorexia B. Heat intolerance C. Constipation D. Palpitations E. Weight loss F. Bradycardia

B, D, E B. Heat intolerance D. Palpitations E. Weight loss B. CORRECT: Hyperthyroidism increases the client's metabolism, causing heat intolerance. D. CORRECT: Hyperthyroidism increases the client's metabolism, causing palpitations. E. CORRECT: Hyperthyroidism increases the client's metabolism, causing weight loss.

A nurse is reinforcing teaching with a client who has a new prescription for levothyroxine to treat hypothyroidism. Which of the following information should the nurse include in the teaching? (Select all that apply.) A. Weight gain is expected while taking this medication. В. Medication should not be discontinued without the advice of the provider. C. Follow-up blood TSH levels should be obtained. D. Take the medication on an empty stomach. E. Use fiber laxatives for constipation.

B,C,D В. Medication should not be discontinued without the advice of the provider. C. Follow-up blood TSH levels should be obtained. D. Take the medication on an empty stomach. B. CORRECT: The provider carefully titrates the dosage of this medication. It should be increased slowly until the client reaches a euthyroid state. The client should not discontinue the medication unless directed to do so by the provider. C. CORRECT: Blood TSH levels are used to monitor the effectiveness of the medication. D. CORRECT: The medication should be taken on an empty stomach to promote absorption.

Anurse is providing medication teaching for a client who has Addison's disease and is taking hydrocortisone. Which of the following instructions should the nurse include? (Select all that apply.) A. Take the medication on an empty stomach. В. Notify the provider of any illness or stress. C. Report any manifestations of weakness or dizziness. D. Do not discontinue the medication suddenly. E. Eat a low-sodium diet.

B,C,D В. Notify the provider of any illness or stress. C. Report any manifestations of weakness or dizziness. D. Do not discontinue the medication suddenly. B. CORRECT: Physical and emotional stress increase the need for hydrocortisone. The provider can increase the dosage when stress occurs. C. CORRECT: Weakness and dizziness are indications of adrenal insufficiency. The client should report these indications to the provider. D. CORRECT: Rapid discontinuation can result in adverse effects, including acute adrenal insufficiency. If hydrocortisone is to be discontinued, the dose should be tapered.

Which health promotion activity(ies) will the nurse recommend to prevent harm in a client with type 2 diabetes? Select all that apply. A. "Avoid all dietary carbohydrate and fat." B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols." D. "Be sure to take your antidiabetes drug right before you engage in any type of exercise." E. "Keep your feet warm in cold weather by using either a hot water bottle or a heating pad." F. "Avoid foot damage from shoe-rubbing by going barefoot or wearing flip-flops when you are at home."

B. "Have your eyes and vision assessed by an ophthalmologist every year." C. "Reduce your intake of animal fat and increase your intake of plant sterols."

A nurse is caring for a client who asks why the provider bases the medication regimen on HbA1c results instead of the log of morning fasting blood glucose results. Which of the following responses should the nurse make? A. "HbA1c measures how well insulin is regulating your blood glucose between meals." B. "HbA1c indicates how well your have regulated your blood glucose over the past 120 days." C. "HbA1c is the first test your doctor prescribed to determine that you have diabetes." D. "HbA1c determines if the your doctor should adjust your insulin dosage."

B. "HbA1c indicates how well your have regulated your blood glucose over the past 120 days." B. CORRECT: HbA1c measures blood glucose control over the past 120 days

A nurse is providing teaching for a client who has a new diagnosis of hypertension and a new prescription for spironolactone 25 mg/day. Which of the following statements by the client indicates an understanding of the teaching? A. "I should eat a lot of fruits and vegetables, especially bananas and potatoes." B. "I will report any changes in heart rate to my provider." C. "I should replace the salt shaker on my table with a salt substitute." D. "I will decrease the dose of this medication when I no longer have headaches and facial redness."

B. "I will report any changes in heart rate to my provider." B. CORRECT: Teach the client to monitor their heart rate and report any changes to the provider.

A client with diabetes who now has chronic albuminuria asks the nurse how this change will affect his health. How will the nurse answer this question? A. You will need to limit your intake of dietary albumin and other proteins to reduce the albuminuria." B. "This change indicates beginning kidney problems and requires good blood glucose control to prevent more damage." C. "Your risk for developing urinary tract infections is greatly increased, requiring the need to take daily antibiotics for prevention." D. "From now on you will need to limit your fluid intake to just 1 L daily and completely avoid caffeine to protect your kidneys."

B. "This change indicates beginning kidney problems and requires good blood glucose control to prevent more damage."

A nurse is planning care for a client who has septic shock. Which of the following actions is the priority for the nurse to take? A. Maintain adequate fluid volume with IV infusions. B. Administer antibiotic therapy. C. Monitor hemodynamic status. D. Administer vasopressor medication.

B. Administer antibiotic therapy. B. CORRECT: The greatest risk to the client is injury from elimination endotoxins and mediators from bacteria. The priority intervention is to administer antibiotics, which will reduce vasodilation.

A nurse is preparing to administer a morning dose of insulin aspart to a client who has type 1 diabetes mellitus. Which of the following actions should the nurse take? A. Check blood glucose immediately after breakfast. B. Administer insulin when breakfast arrives. C. Hold breakfast for 1 hr after insulin administration. D. Clarify the prescription because insulin should not be administered at this time.

B. Administer insulin when breakfast arrives. B. CORRECT: Administer insulin aspart when breakfast arrives to avoid a hypoglycemic episode. Insulin aspart is rapid-acting and should be administered 5 to 10 min before breakfast.

A nurse is caring for a client who has chronic venous insufficiency and a prescription for thigh-high compression stockings. Which of the following actions should the nurse take? A. Elevate the client's legs for 10 min, two to three times daily while wearing stockings. B. Apply the stockings in the morning upon awakening and before getting out of bed. C. Roll the stockings down to the knees to relieve discomfort on the legs. D. Remove the stockings while out of bed for 1 hr, four times a day, to allow the legs to rest.

B. Apply the stockings in the morning upon awakening and before getting out of bed. B. CORRECT: Applying stockings in the morning upon awakening and before getting out of bed reduces venous stasis and assists in the venous return of blood to the heart. Legs are less edematous at this time.

A nurse is preparing to administer packed RBCs to a client who has a Hgb of 8 g/dL. Which of the following actions should the nurse plan to take during the first 15 min of the transfusion? A. Obtain consent from the client for the transfusion. B. Assess for an acute hemolytic reaction. C. Explain the transfusion procedure to the client. D. Obtain blood culture specimens to send to the lab.

B. Assess for an acute hemolytic reaction. B. CORRECT: Assess for an acute hemolytic reaction during the first 15 min of the transfusion. This form of a reaction can occur following the transfusion of as little as 10 mL of blood product.

2. Which instruction/precaution does the nurse teach a client to prevent harm during a 24-hour urine specimen collection? A. Be sure to keep the specimen cool for the entire collection period B. Avoid splashing urine in the container when a preservative is present C. Add the preservative to the collection container before adding any urine. D. Discard the first specimen that marks the beginning of the 24-hour test period.

B. Avoid splashing urine in the container when a preservative is present

A nurse is reviewing laboratory reports of a client who has HHS. Which of the following findings should the nurse expect? A. Blood pH 7.2 B. Blood osmolarity 350 mOsm/L C. Blood potassium 3.8 mg/dL D. Blood creatinine 0.8 mg/dL

B. Blood osmolarity 350 mOsm/L B. CORRECT: A client who has HHS would have a blood osmolarity greater than 320 mOsm/L.

Anurse in a provider's office is reviewing the health record of a client who is being evaluated for Graves' disease. The nurse should identify that which of the following laboratory results is an expected finding? A. Decreased thyrotropin receptor antibodies B. Decreased thyroid-stimulating hormone (TSH) C. Decreased free thyroxine index D. Decreased triiodothyronine

B. Decreased thyroid-stimulating hormone (TSH) B. CORRECT: In the presence of Graves' disease, low TSH is an expected finding. The pituitary gland decreases the production of TSH when thyroid hormone levels are elevated.

A nurse is caring for a client who is receiving warfarin for anticoagulation therapy. Which of the following laboratory test results indicates to the nurse that the client needs an increase in the dosage? A. aPTT 38 seconds B. INR 1.1 C. PT 22 seconds D. D-dimer negative

B. INR 1.1 B. CORRECT: INR of 1.1 is within the expected reference range for a client who is not receiving warfarin. However, this value is subtherapeutic for anticoagulation therapy. Expect the client to receive an increased dosage of warfarin until the INR is 2 to 3.

While making rounds the nurse finds a client with type 1 diabetes mellitus pale, sweaty, and slightly confused; the client can swallow. The client's blood glucose level check is 48 mg/dL (2.7 mmol/L). What is the nurse's best first action to prevent harm? A. Call the pharmacy and order a STAT does of glucagon. B. Immediately give the client 30 g of glucose orally. C. Start an IV and administer a small amount of a concentrated dextrose solution. D. Recheck the blood glucose level and call the Rapid Response Team.

B. Immediately give the client 30 g of glucose orally.

Twenty minutes later, the client is admitted to the ICU for DKA management. The client is receiving IV regular insulin with frequent finger sticks to check glucose level. His potassium level is 2.5, and IV potassium supplements have been ordered. What assessment must the nurse make before giving the IV potassium? A. Respiratory rate of less than 24/min B. Production of at least 30 mL/hr of urine C. Oriented to time, place, and person D. Finger stick glucose of less than 200 mg/dL

B. Production of at least 30 mL/hr of urine

Which assessment finding in a 40-year-old client is most relevant for the nurse to assess further for a possible endocrine problem? A. He has lost 10 Ib in the past month following a low-carbohydrate eating plan B. The client reports now needing to shave only once weekly instead of daily. C. His new prescription for eyeglasses is for a higher strength. D. The client's father died of a stroke at age 70 years.

B. The client reports now needing to shave only once weekly instead of daily.

A nurse in a clinic receives a phone call from a client seeking information about a new prescription for erythropoietin. Which of the following information should the nurse review with the client? A. The client needs an erythrocyte sedimentation rate (ESR) test weekly. B. The client should have their hemoglobin checked twice a week. C. Oxygen saturation levels should be monitored. D. Folic acid production will increase.

B. The client should have their hemoglobin checked twice a week. B. CORRECT: Include in the teaching that hemoglobin and hematocrit are monitored twice a week until the targeted levels are reached.

How will the nurse modify insulin injection technique for a client who is 5 feet 10 inches tall and weighs 106 lb (48.1 kg)? A. Use a 6-mm needle and inject at a 90-degree angle. B. Use a 6-mm needle and inject at a 45-degree angle. C. Use a 12-mm needle and inject at a 90-degree angle. D. Use a 12-mm needle and inject at a 45-degree angle.

B. Use a 6-mm needle and inject at a 45-degree angle.

A nurse is assessing a client who is 12 hr postoperative following a thyroidectomy. Which of the following findings is indicative of thyroid crisis? (Select all that apply.) A. Bradycardia B. Hypothermia C. Dyspnea D. Abdominal pain E. Mental confusion

C, D, E C. Dyspnea D. Abdominal pain E. Mental confusion C. CORRECT: Excessive levels of thyroid hormone can cause the client to experience dyspnea. D. CORRECT: When thyroid crisis occurs, the client can experience gastrointestinal conditions (vomiting, diarrhea, and abdominal pain). E. CORRECT: Excessive thyroid hormone levels can cause the client to experience mental confusion.

A nurse is monitoring a client who began receiving a unit of packed RBCs 10 min ago. Which of the following findings should the nurse identify as an indication of a febrile transfusion reaction? (Select all that apply.) A. Temperature change from 37° C (98.6° F) pretransfusion to 37.2° C (99.0° F) B. Current blood pressure 178/90 mm Hg C. Heart rate change from 88/min pretransfusion to 120/min D. Client report of itching E. Client appears flushed

C, E. C. Heart rate change from 88/min pretransfusion to 120/min E. Client appears flushed C. CORRECT: Tachycardia is an indication of a febrile transfusion reaction. E. CORRECT: A flushed appearance of the client can indicate a febrile transfusion

A nurse is providing discharge teaching for a client who had a transsphenoidal hypophysectomy. Which of the following instructions should the nurse include? (Select all that apply.) A. Brush teeth after every meal or snack. B. Avoid bending at the knees. C. Eat a high-fiber diet. D. Notify the provider of increased swallowing. E. Notify the provider of a diminished sense of smell.

C,D C. Eat a high-fiber diet. D. Notify the provider of increased swallowing. C. CORRECT: To avoid constipation, which contributes to increased intracranial pressure, the client should eat a high-fiber diet and take docusate. D. CORRECT: Increased swallowing is an indication of leakage of cerebrospinal fluid. The client should notify their provider.

A nurse is caring for a client who has a deep-vein thrombosis (DVT) and has been taking unfractionated heparin for 1 week. Two days ago, the provider also prescribed warfarin. The client asks the nurse about receiving both heparin and warfarin at the same time. Which of the following statements should the nurse give? A. "I will remind your provider that you are already receiving heparin." B. "Your laboratory findings indicated that two anticoagulants were needed." C. "It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued." D. "Only one of these medications is being given to treat your deep-vein thrombosis."

C. "It takes 3 to 4 days before the therapeutic effects of warfarin are achieved, and then the heparin can be discontinued." C. CORRECT: Warfarin depresses synthesis of clotting factors but does not have an effect on clotting factors that are present. It takes 3 to 4 days for the clotting factors that are present to decay and for the therapeutic effects of warfarin to occur.

A nurse is providing preoperative teaching for a client who requests autologous donation in preparation for a scheduled orthopedic surgical procedure. Which of the following statements should the nurse include in the teaching? A. "You should make an appointment to donate blood 8 weeks prior to the surgery." B. "If you need an autologous transfusion, the blood your brother donates can be used." C. "You can donate blood each week if your hemoglobin is stable." D. "Any unused blood that is donated can be used for other clients."

C. "You can donate blood each week if your hemoglobin is stable." C. CORRECT: Beginning 6 weeks prior to surgery, the client can donate blood each week for autologous transfusion if their Hgb and Hct remain

A nurse is planning to teach a client who is being evaluated for Addison's disease about the adrenocorticotropic hormone (ACTH) stimulation test. The nurse should base the instructions on which of the following? A. The ACTH stimulation test measures the response by the kidneys to ACTH. B. In the presence of primary adrenal insufficiency, plasma cortisol levels rise in response to administration of ACTH. C. ACTH is a hormone produced by the pituitary gland. D. The client is instructed to take a dose of ACTH by mouth the evening before the test.

C. ACTH is a hormone produced by the pituitary gland. C. CORRECT: Secretion of corticotropin-releasing hormone from the hypothalamus prompts the pituitary gland to secrete ACTH.

A nurse in the emergency department is admitting a client who has a possible dissecting abdominal aortic aneurysm. Which of the following actions is the priority for the nurse to take? A. Administer pain medication as prescribed. B. Provide a warm environment. C. Administer IV fluids as prescribed. D. Initiate a 12-lead ECG.

C. Administer IV fluids as prescribed. C. CORRECT: When using the airway, breathing, circulation approach to client care, determine that the priority is on administering IV fluids to the client. The client is at risk of inadequate circulatory volume due to profuse sweating related to the pain and feeling of fullness related to the aneurysm and to possible leaking or rupture of the aneurysm.

A nurse is caring for a client who has idiopathic thrombocytopenic purpura (ITP). The nurse should notify the provider and report possible small-vessel clotting when which of the following is assessed? A. Petechiae on the upper chest B. Hypotension C. Cyanotic nail beds D. Severe headache

C. Cyanotic nail beds C. CORRECT: Cyanotic nail beds indicate microvascular clotting is occurring and should be immediately reported to avoid ischemic loss of the fingers or toes.

Which precaution is a priority for the nurse to teach a client prescribed pramlintide to prevent harm? A. Only take this drug once weekly. B. Do not drink alcohol when taking this drug. C. Do not mix in the same syringe with insulin. D. Report any genital itching to your primary health care provider.

C. Do not mix in the same syringe with insulin.

A client returning to the clinic 7 weeks after hematopoietic stem cell transplantation for leukemia has a total white blood cell (WBC) count of 5200/mm° (5.2 x 10°/L) and a neutrophil count of 3000/mm (3 x 10° /L). What is the nurse's priority action in view of these values? a. Notify the oncology health care provider immediately b. Assess the client for other symptoms of infection C. Document the laboratory report as the only action d. Obtain urine specimen, sputum specimen, and chest x-ray

C. Document the laboratory report as the only action

A nurse is preparing to administer morning doses of insulin glargine and regular insulin to a client who has a blood glucose 278 mg/dL. Which of the following actions should the nurse take? A. Draw up the regular insulin and then the glargine insulin in the same syringe. B. Draw up the glargine insulin then the regular insulin in the same syringe. C. Draw up and administer regular and glargine insulin in separate syringes. D. Administer the regular insulin, wait 1 hr, and then administer the glargine insulin.

C. Draw up and administer regular and glargine insulin in separate syringes. C. CORRECT: Administer each insulin as a separate injection. These insulins are not compatible and should not be drawn up in the same syringe.

A nurse is caring for a client who is experiencing wheezing and swelling of the tongue. Which of the following medications should the nurse anticipate administering first? A. Methylprednisolone B. Diphenhydramine C. Epinephrine D. Dobutamine

C. Epinephrine C. CORRECT: When using the airway, breathing, circulation approach to client care, place the priority on administering epinephrine to the client. This is a rapid-acting medication that promotes effective oxygenation and is used to treat anaphylactic shock.

A nurse is assessing a client and suspects the client is experiencing DIC. Which of the following physical findings should the nurse anticipate? A. Bradycardia B. Hypertension C. Epistaxis D. Xerostomia

C. Epistaxis C. CORRECT: Epistaxis is unexpected bleeding of the gums and nose and is a finding indicative of DIC.

The family of a client receiving a blood transfusion report with distress to the nurse that although the blood bag hanging has the client's name on it, the bag abel says B negative and the client's blood type is B positive. What is the nurse's priority action? A. Alert the blood bank and Rapid Response Team about a potential error. B. Thank the family for being alert and preventing a serious complication. C. Explain that a person who is Rh positive can receive Rh negative blood. D. Immediately go and stop the infusion but keep the IV line open with normal saline.

C. Explain that a person who is Rh positive can receive Rh negative blood.

A nurse is teaching a client who has a new prescription for ferrous sulfate. Which of the following information should the nurse include in the teaching? A. Stools will be dark red. B. Take with a glass of milk if gastrointestinal distress occurs. C. Foods high in vitamin C will promote absorption. D. Take for 14 days.

C. Foods high in vitamin C will promote absorption. C. CORRECT: Vitamin C enhances the absorption of iron by the intestinal tract.

A nurse is caring for a client who is 6 hr postoperative following a transsphenoidal hypophysectomy. The nurse should test the client's nasal drainage for the presence of which of the following? A. RBCs B. Ketones C. Glucose D. Streptococci

C. Glucose C. CORRECT: Cerebral spinal fluid contains glucose. Test nasal drainage for glucose.

A nurse is caring for a client who is admitted to the emergency department with a blood pressure of 266/147 mm Hg. The client reports a headache and double vision. The client states, "I ran out of my diltiazem 3 days ago, and I am unable to purchase more." Which of the following actions should the nurse take first? A. Administer acetaminophen for headache. B. Provide teaching regarding the importance of not abruptly stopping an antihypertensive. C. Obtain IV access and prepare to administer an IV antihypertensive. D. Call social services for a referral for financial assistance in obtaining prescribed medication.

C. Obtain IV access and prepare to administer an IV antihypertensive. C. CORRECT: The greatest risk to the client is injury due to a blood pressure of 266/147 mm Hg, which can be life-threatening and should be lowered as soon as possible. Obtaining IV access will permit administration of an IV hypertensive, which will act more rapidly than by the oral route.

A nurse is caring for a client who has blood glucose 52 mg/dL. The client is lethargic but arousable. Which of the following actions should the nurse perform first? A. Recheck blood glucose in 15 min. B. Provide a carbohydrate and protein food. C. Provide 15 g of simple carbohydrates. D. Report findings to the provider.

C. Provide 15 g of simple carbohydrates. C. CORRECT: The greatest risk to the client is injury from hypoglycemia; theretore, the priority action to take is to administer 15 to 20 g of a rapidly-absorbed carbohydrate (grape juice).

A nurse is reviewing the medical record for a client who is to begin therapy for DKA. Which of the following prescriptions should the nurse expect? A. Administer an IV infusion of regular insulin at 0.3 unit/kg/hr. B. Administer a slow IV infusion of 3% sodium chloride. C. Rapidly administer an IV infusion of 0.9% sodium chloride. D. Add glucose to the IV infusion when blood glucose is 350 mg/dL.

C. Rapidly administer an IV infusion of 0.9% sodium chloride. C. CORRECT: Expect to rapidly administer an IV infusion of 0.9% sodium chloride, an isotonic fluid, as prescribed to maintain blood perfusion to vital organs. The initial infusion for a client who has an elevated sodium would be 0.45% sodium chloride.

A nurse in an urgent care clinic is obtaining a history from a client who has type 2 diabetes mellitus and a recent diagnosis of hypertension. This is the second time in 2 weeks that the client experienced hypoglycemia. Which of the following client data should the nurse report to the provider? A. Takes psyllium daily as a fiber laxative B. Drinks skim milk daily as a bedtime snack C. Takes metoprolol daily after meals D. Drinks grapefruit juice daily with breakfast

C. Takes metoprolol daily after meals C. CORRECT: Metoprolol can mask the effects of hypoglycemia in clients who have diabetes mellitus.

Which statement regarding trophic (tropic) hormones is true? A. All are categorized as catecholamines. B. Responses are independent of target tissue receptors. C. Their target tissues are always another endocrine gland. D. They represent the final hormone secreted in a complex negative feedback pathway.

C. Their target tissues are always another endocrine gland.

A nurse is providing teaching to a client who has a new diagnosis of diabetes insipidus. Which of the following client statements indicates an understanding of the teaching? A. "I can drink up to 2 quarts of fluid a day." B. "I will need to use insulin to control my blood glucose levels." C. "I should expect to gain weight during this illness." D. "I might experience confusion or balance problems."

D. "I might experience confusion or balance problems." D. CORRECT: Confusion and ataxia are findings associated with DI.

A nurse is caring for a group of clients. Which of the following clients is at risk for obstructive shock? A. A client who is having occasional PVCs on the ECG monitor B. A client who has been experiencing vomiting and diarrhea for several days C. A client who has a gram-negative bacterial infection D. A client who has a pulmonary arterial stenosis

D. A client who has a pulmonary arterial stenosis D. CORRECT: Obstructive shock results from decreased cardiac function by a noncardiac cause, such as with pulmonary arterial stenosis or hypertension, or thoracic tumor.

When preparing to administer a prescribed subcutaneous dose of NPH insulin from an open vial taken from a medication drawer to a client with diabetes, the nurse notes the solution is cloudy. What action will the nurse perform to ensure client safety? A. Warm the vial in a bowl of warm water until it reaches normal body temperature. B. Return the vial to the pharmacy and open a fresh vial of NPH insulin. C. Roll the vial between the hands until the insulin is clear. D. Check the expiration date and draw up the insulin dose.

D. Check the expiration date and draw up the insulin dose.

A nurse is teaching a newly licensed nurse about heparin-induced thrombocytopenia. Which of the following risk factors for this disorder should the nurse include in the teaching? A. Warfarin therapy for atrial fibrillation B. Placental abruption C. Systemic lupus erythematosus D. Heparin therapy for deep-vein thrombosis

D. Heparin therapy for deep-vein thrombosis D. CORRECT: The client who is receiving heparin therapy for longer than 1 week is at increased risk for the development of HIT.

A nurse in a clinic is caring for a client who has suspected anemia. Which of the following laboratory test results should the nurse expect? A. Iron 90 mcg/dL B. RBC 6.5 million/uL C. WBC 4,800 mms D. Hgb 10 g/dL

D. Hgb 10 g/dL D. CORRECT: Hgb of 10 g/dL is below the expected reference range and is an expected finding of anemia.

The health care provider diagnoses the client with acute sickle cell crisis. Which drug does the nurse anticipate will be prescribed for pain control at this time? (Select all that apply.) A. Meperidine IV push prn B. Acetaminophen rectally prn C. Morphine sulfate IM scheduled doses D. Hydromorphone IV push scheduled doses E. Morphine sulfate IV push scheduled doses

D. Hydromorphone IV push scheduled doses E. Morphine sulfate IV push scheduled doses

A nurse is planning care for a client who has acromegaly and is postoperative following a transsphenoidal hypophysectomy. Which of the following interventions should the nurse include in the plan? A. Maintain the client in a low-Fowler's position. B. Encourage deep breathing and coughing. C. Encourage the client to brush their teeth when awake and alert. D. Observe dressing drainage for the presence of glucose.

D. Observe dressing drainage for the presence of glucose. D. CORRECT: The nurse should monitor the drainage to the mustache dressing and observe for the presence of glucose, which would indicate the presence of CSF. Notify the provider if this occurs.

A nurse preceptor is observing a newly licensed nurse on the unit who is preparing to administer a blood transfusion to an older adult client. Which of the following actions by the newly licensed nurse indicates an understanding of the procedure? A. Inserts an 18-gauge IV catheter in the client B. Verifies blood compatibility and expiration date of the blood with an assistive personnel (AP) C. Administers dextrose 5% in 0.9% sodium chloride IV with the transfusion D. Obtains vital signs every 15 min throughout the procedure.

D. Obtains vital signs every 15 min throughout the procedure. D. CORRECT: Check the older adult client's vital signs every 15 min throughout the transfusion to allow for early detection of fluid overload or other transfusion

A nurse is assessing a client who has chronic peripheral arterial disease (PAD). Which of the following findings should the nurse expect? A. Edema around the ankles and feet B. Ulceration around the medial malleoli C. Scaling eczema of the lower legs with stasis dermatitis D. Pallor on elevation of the limbs, and rubor when the limbs are dependent

D. Pallor on elevation of the limbs, and rubor when the limbs are dependent D. CORRECT: In a client who has chronic PAD, pallor is seen in the extremities when the limbs are elevated, and rubor occurs when they are lowered.

A nurse is teaching a client who has a new diagnosis of severe peripheral arterial disease. Which of the following instructions should the nurse include? A. Wear tightly-fitted insulated socks with shoes when going outside. B. Elevate both legs above the heart when resting. C. Apply a heating pad to both legs for comfort. D. Place both legs in dependent position while sleeping.

D. Place both legs in dependent position while sleeping. D. CORRECT: Instruct the client to place their legs in a dependent position, such as hanging off the edge of the bed while sleeping. This can alleviate swelling and discomfort of the legs.

The nurse reviewing the preadmission testing laboratory values for a 62-year-old client scheduled for a total knee replacement finds an A1C value of 6.2%. How will the nurse interpret this finding? A. The client's A1C is completely normal. B. The client has type 1 diabetes mellitus. C. The client has type 2 diabetes mellitus. D. The client has prediabetes mellitus.

D. The client has prediabetes mellitus.

Which intervention is a priority for the nurse to teach the client with polycythemia vera to prevent harm related to injury as a result of impaired platelet function? A. Wear gloves and socks outdoors in cool weather. B. Elevate your feet whenever you are seated C. Drink at least 3 L of liquids per day. D. Use a soft-bristle toothbrush.

D. Use a soft-bristle toothbrush.

A nurse in a provider's office is assessing a client who recently began taking levothyroxine to treat hypothyroidism. Which of the following findings should indicate to the nurse that the client might need a decrease in the dosage of the medication? А. Hand tremors B. Bradycardia C. Pallor D. Slow speech

А. Hand tremors A. CORRECT: Identify hand tremors as a manifestation of hyperthyroidism that can result from thyroid hormone replacement therapy. Report this finding to the provider due to the possible need for a decrease in the dosage of medication.

A nurse is reviewing the laboratory findings for a client who might have hyperthyroidism. The nurse should identify an elevation of which of the following substances as an indication that the client has this disorder? А. Triiodothyronine B. Plasma-free metanephrine C. Urine cortisol D. Urine osmolality

А. Triiodothyronine A. CORRECT: Increased triiodothyronine (T3) indicates hyperthyroidism.

A nurse is providing teaching for a client who is scheduled for a bone marrow biopsy of the iliac crest. Which of the following statements made by the client indicates an understanding of the teaching? A. "This test will be performed while lam lying flat on my back." В. "I will need to stay in bed for about an hour after the test." C. "This test will determine which antibiotic I should take for treatment." D. "I will receive general anesthesia for the test."

В. "I will need to stay in bed for about an hour after the test." B. CORRECT: Inform the client of the need to stay on bed rest for 30 to 60 min following the test to reduce the risk for bleeding.

A nurse is providing instructions to a client who has Graves' disease and has a new prescription for propranolol. Which of the following information should the nurse include? A. "An adverse effect of this medication is jaundice." В. "Take your pulse before each dose." C. "The purpose of this medication is to decrease production of thyroid hormone." D. "You should stop taking this medication if you have a sore throat."

В. "Take your pulse before each dose." B. CORRECT: Propranolol can cause bradycardia. The client should take their pulse before each dose. If there is a significant change, they should withhold the dose and consult the provider.

A nurse in a provider's office is reviewing laboratory results of a client who is being evaluated for secondary hypothyroidism. Which of the following laboratory findings is expected? A. Elevated T4 В. Decreased T3 C. Elevated thyroid stimulating hormone D. Decreased cholesterol

В. Decreased T3 B. CORRECT: Decreased levels of Ta in the blood is an expected finding for a client who has hypothyroidism.

A nurse is caring for a client who has diabetes insipidus. Which of the following urinalysis laboratory findings should the nurse expect? A. Presence of glucose В. Decreased specific gravity C. Presence of ketones D. Presence of red blood cells

В. Decreased specific gravity B. CORRECT: The urine of a client who has diabetes insipidus will be dilute with a urine specific gravity of less than 1.005.

A nurse is assessing a client during a water deprivation test. For which of the following complications should the nurse monitor the client? A. Bradycardia В. Orthostatic hypotension C. Neck vein distention D. Crackles in lungs

В. Orthostatic hypotension B. CORRECT: Monitor for orthostatic hypotension resulting from dehydration during a water deprivation test.

A nurse is completing an integumentary assessment of a client who has anemia. Which of the following findings should the nurse expect? A. Absent turgor В. Spoon-shaped nails C. Shiny, hairless legs D. Yellow mucous membranes

В. Spoon-shaped nails B. CORRECT: Deformities of the nails, such as being spoon-shaped, are findings in a client who has anemia.