Exam4

A nurse is caring for a client who reports difficulty breathing and tingling in both hands. His respiration rate is 36 and he appears very restless. The nurse anticipates which of the following values to be outside the expected reference range if the client is experiencing respiratory alkalosis

PaCO2

A 75 year old diabetic client presents to the ER after collapsing in a local department store. The client has been fasting for days and testing had found ketones in the urine. Which acid base imbalance would the nurse expect to assess in the client?

Metabolic acidosis

A client has hypokalemia. What question that the nurse asks obtains the most information on a possible cause?

"Do you use diuretics or laxatives?"

The nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a correct statement following the nurse education they received concerning the medication regimen?

"I will wear a medical alert bracelet"

A nurse is caring for a client who has deep vein thrombosis and has been on heparin continuous infusion for 5 days. The provider prescribes warfarin PO without discontinuing the heparin. The client asks the nurse why both anticoagulants are necessary. Which of the following statements should the nurse make?

"Warfarin takes several days to work, so the IV heparin will be used until the warfarin reaches a therapeutic level."

A client diagnosed with type 1 diabetes mellitus administers a dose of NPH insulin at 7:00am. At which of the following times would this client most likely exhibit hypoglycemia?

1400

Phenazopyridine is prescribed for symptomatic relief of pain resulting from a lower urinary tract infection. The nurse should provide the client with what information regarding this medication?

A reddish orange discoloration of the urine may occur

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a DVT? (SATA)

A. Assess legs for redness or swelling B. Turn patient every 2 hours C. Administer ordered subcutaneous Heparin

Which of the following assessment techniques can the nurse use to determine if a client is experiencing hypocalcemia?

A. Trousseau's sign B. Chvostek's sign F. Check the chart to evaluate recent labs

Which action by the nurse is most effective to prevent becoming exposed to the HPV virus?

Always use standard precautions with all clients in the workplace

A client is worried about contracting influenza. What is the nurses best response to the client?

Did you receive a flu vaccine this year?

A client with diabetes mellitus is prescribed to take insulin glargine once daily and regular insulin four times daily. How will the nurse teach the client to take these two medications when the first dose of regular insulin should be given at the same time of day as the insulin glargine dose

Draw up and inject the insulin glargine first, and then draw up and inject the dose of regular insulin in a separate syringe

A client with diabetes mellitus has hot dry skin; rapid and deep respirations; and fruit odor to his breath. The charge nurse observes a newly graduated registered nurse performing all the following tasks. Which action requires that the charge nurse intervene immediately?

Encouraging the client to drink 4oz of orange juice

The nurse is caring for a client post spinal cord injury. What interventions will the nurse provide to minimize the risk of autonomic dysreflexia?

Ensure strict adherence to a bowel retraining program

A nurse is caring for a client who is experiencing a seizure that is continuing after 5 minutes. What is the nurses priority action?

Establish airway

A nurse is instructing a client diagnosed with type 2 diabetes mellitus on diagnostic tests used to evaluate how well the disorder has been managed. The nurse should instruct the client on which of the following diagnostic tests that will provide this intervention?

Glycosylated hemoglobin

The nurse is teaching a client who is newly diagnosed with epilepsy. Which statement by the client indicates a need for further teaching concerning the drug regimen?

I can skip a couple of pills if they make me ill

The nurse is planning care for a client who has acute dysphagia. Which of the following nursing interventions should be included in the plan of care?

Instruct client to til head forward and lower chin to swallow

Which action should the nurse take when caring for a newly admitted client receiving a blood transfusion?

Instruct the client to report any itching, chest pain, or dyspnea Additional options: Verify consent, hang lactated ringers with the blood

A client is admitted to the emergency room with a respiratory rate of 6/min. Arterial blood gasses (ABGs) have been drawn and reveal to the following values: pH 7.22, PaCO2 68, HCO3 26, PaO2 74. Which of the following is an appropriate analysis of these ABGs?

Respiratory acidosis

A client with chronic obstructive pulmonary disease (COPD) is admitted to the hospital. How can the nurse best participate the client to improve gas exchange?

Sitting up at the bedside or in the chair and leaning slightly forward

A client receiving continuous tube feedings develops restlessness, agitation, and weakness. Which laboratory result is most important to report to the health care provider?

Sodium 154

The nurse is caring for a client who is about to have immunotherapy initiated due to severe allergies. Knowing that this patient is being exposed to a known allergen, what intervention does the nurse implement to provide for client safety this allergy treatment?

Stay with the client and ensure that emergency equipment is in the room

The nurse is changing the central line of a client receiving TPN and notes that the catheter insertion site appears reddened. The nurse should next assess what?

The client temperature

The laboratory values of a client who has diabetes mellitus include a fasting blood glucose level of 196mg/dl and hemoglobin A1C of 6.8/ What are the nurses interpretations of these findings?

The clients glucose control for the past 24 hours has been poor, but the overall control is good.

A client asks the nurse why it is important to be weighed every day if he has right sided heart failure. What is the nurses best response?

Weight is one of the best indications that you are gaining or losing fluid