NUR3262 Exam 2

A nurse is providing care for four clients on a medical-surgical unit which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

A client who has protein calorie malnutrition A client who has right-sided heart failure and 4+ edema to the lower extremities A client who has postoperative delirium

A nurse is teaching a nursing student how to accurately measure blood pressure. What should be emphasized?

A cuff that is too small will give a false high blood pressure

A nurse is teaching a client who has type 1 diabetes mellitus about exercise. which of the following instructions should the nurse include?

Do not exercise if ketones are present in your urine.

A nurse is assessing a client who has chronic venous insufficiency. Which of the following findings should the nurse expect?

Edema

A nurse is caring for a client in the emergency department (ED) Drag 1 condition and 1 client finding to fill in each blank in the following sentence. The client is exhibiting manifestations of ________________due to the client's _____________

Encephalopathy, Ammonia level

A 52-year-old patient with no previous history of hypertension has a blood pressure of 188/106. What will you do that?

Ensure correct cuff size and recheck the blood pressure in opposite extremity

Insulin is given for someone experiencing symptoms of diaphoresis, sweating, and tremors.

False

A nurse is caring for a client who is diabetic and reports a headache, restlessness, fatigue, and hunger. Then nurse should identify that the client is likely experiencing which of the following conditions?

Hypoglycemia

A nurse is preparing to administer lispro insulin to a client who has type 1 diabetes mellitus. which of the following actions should the nurse take?

Inject the insulin 15 min before a meal

A nurse is caring for a client who has peripheral arterial disease (PAD). which of the following symptoms should the nurse expect to find in the early stage of the disease?

Intermittent claudication

Which of the following would be inconsistent with a hypertensive urgency?

Intracranial hemorrhage

A patient was recently diagnosed with Type 1 diabetes mellitus and receives insulin. Which laboratory test will the nurse assess?

Potassium

A nurse is teaching a client who has chronic kidney failure about planning a low-protein diet. the client states, "why do i have be concerned about protein?" which of the following responses should the nurse make?

"A low-protein diet reduces the risk for uremia"

A nurse is reviewing guidelines to prevent during periods of illness with a client who has type 1 diabetes mellitus which of the following instructions should the nurse include in the teaching?

"Check your urine for ketones when blood glucose levels are greater than 240 mg/dL"

Which statement indicates teaching about lifestyle modifications has been effective for a newly diagnosed HTN patient?

"I know I need to give up my cigarettes and alcohol"

A nurse is teaching a client who has a new diagnosis of type 1 diabetes mellitus about self-administration of insulin. which of the following instructions should the nurse include?

"Store the current bottle of insulin at room temperature"

A nurse is teaching a client who is taking metformin XR for type diabetes mellitus. which of the following instructions should the nurse include in the teaching?

"Take the medication with a meal"

A nurse is teaching a client about self-administered peritoneal dialysis. Which of the following statements by the client indicates a need for further teaching?

"The microwave in the kitchen can warm the solution before I use it"

A client who has Type 2 diabetes mellitus asks the nurse, "Why did I develop diabetes?" Which of the following responses should the nurse make?

"Your body has insulin resistance and decreased insulin secretion"

A nurse is caring for a client with diabetes mellitus who is prescribed regular insulin via a sliding scale. After administering the correct dose at 0715, the nurse should ensure the client receives breakfast at which of the following times?

0745

Which of the following patients does not have a risk factor of hypertension?

A 35-year-old female with a total cholesterol level of 100

Lisinopril is a beta blocker

False

A nurse is caring for a client who has heart failure and a potassium level of 2.4meq / l the nurse should identify which of the following medications as the cause of the client's low potassium level?

Furosemide

A nurse is caring for a client who has cirrhosis and has a prescription for bumetanide. when delivering the client's lunch tray which of the following items should the nurse identify as contraindicated for the client?

Ham sandwich

What are some of the most common symptoms of hypertension?

Headaches, blurry vision, chest pain

What is a common side effect of Losartan and its class of medication?

Hyperkalemia

Which method of insulin administration would be used in the initial treatment of hyperglycemia in a client with DKA?

IV bolus, followed by continuous infusion

Clients with Type 1 Diabetes mellitus require which of the following changes to their daily routine during periods of infection?

More insulin

Which of the following is not considered a nonpharmacologic method to reduce blood pressure?

Multivitamins

A nurse is performing a monofilament sensory assessment of a client who has diabetes mellitus. when performing this assessment, for which of the following complications is the nurse monitoring?

Neuropathy

The RN is evaluating a 45-year-old patient diagnosed with Type 2 Diabetes mellitus. Which symptom is clinically classic to Diabetes mellitus?

Polydipsia

Gen has Type 1 diabetes mellitus and receives insulin. She tells the RN she likes to have a glass of wine with dinner. What is the risk?

The alcohol could predispose you to hypoglycemia

Which of the following causes of Hyperglycemic Hyperosmolar Non-Ketotic Syndrome (HHNS) is most common?

Undiagnosed diabetes mellitus

A nurse administers desmopressin to a client who has a diagnosis of diabetes insipidus. the nurse recognizes that which the following laboratory findings indicate a therapeutic effect of the medication?

Urine specific gravity 1.015

A nurse is caring for a client who has a new diagnosis of essential hypertension. the nurse should monitor the client for which of the following findings that is consistent with this diagnosis?

Vertigo

A nurse is developing a plan of care for a client who is to begin receiving peritoneal dialysis. which of the following interventions should the nurse implement to ensure proper dialysate exchange?

Warm the dialysate solution prior to instillation.

When treating hypertensive emergencies, the nurse identifies the most appropriate route of administration for antihypertensive agents as being which of the following? a) Sublingual b) Continuous IV infusion c) Oral d) Intramuscular

b) Continuous IV infusion

Rotating injection sites when administering insulin prevents which of the following complications? a. Insulin edema b. Insulin lipodystrophy c. Insulin resistance d. Systemic allergic reactions

b. Insulin lipodystrophy

A nurse is assessing a client to identify risk factors for disease. Which of the following findings is a risk factor for metabolic syndrome?

Large waist size

A nurse is assessing a male client who has advanced peripheral artery disease (PAD). which of the following findings should the nurse expect?

Leg pain at rest

The RN is teaching a patient about their insulin as part of the discharge plan. Which has the most repaid onset of action?

Lispro (Humalog)

Which patient with Type 1 Diabetes mellitus would be at the highest risk for developing hypoglycemic unawareness?

A 73-year-old patient who takes propranolol (Inderal)

A nurse is teaching a middle-age client about hypertension which of the following information should the nurse include in the teaching?

"Diuretics are the first type of medication to control hypertension."

The RN is reviewing lab results. Which patient meets the diagnostic criteria for diabetes mellitus?

48-year-old woman with a HbA1C of 8.4%

A nurse working for a home health agency is teaching a client who has diabetes mellitus about disease management. which of the following glycosylated hemoglobin (HBA1c) values should the nurse include in the teaching as an indicator that the client is appropriately controlling his glucose levels?

6.3%

A patient with Diabetes mellitus is NPO for surgery and states they feel their blood glucose is low. You check the blood glucose and find it to be 52. Next step?

Administer Dextrose 50% IV per protocol

A nurse is assessing a female client who is at risk for developing type 2 diabetes mellitus. the nurse should identify that which of the following manifestations increases the client's risk for developing type 2 diabetes?

Blood pressure 138/98 mm Hg

A nurse is providing teaching to a client who has a new diagnosis of type 2 diabetes mellitus. the nurse should recognize the client understands the teaching when he identifies which of the following as manifestations of hypoglycemia? (Select all that apply

Blurred vision Tachycardia Moist, clammy skin

Ben injects his insulin as prescribed, but then gets busy and forgets to eat. What will the best assessment of the nurse reveal? A. The client will be very thirsty. B. The client will complain of nausea. C. The client will need to urinate. D. The client will have moist clammy skin.

D. The client will have moist clammy skin.

A nurse is caring for a 44-year-old client who was admitted with an elevated temperature and abdominal pain Select the top 4 findings that requires immediate follow up.

Potassium 7.0 mEq/L (3.5 to 5 mEq/L) No dialysis for 24 hr Abdomen rigid with decreased bowel sounds Crackles throughout lungs WBC count 17,000/mm3 (Normal Finding: 5,000 to 10,000/mm3)

A nurse is caring for a client who is undergoing initial peritoneal dialysis. which of the following should the nurse report immediately to the provider?

Purulent dialysate outflow

Which of the following contributes to the development of secondary hypertension?

Renal disease

Which of the following chronic complications is associated with diabetes?

Retinopathy, neuropathy, and coronary artery disease

A nurse is assessing a client who has peritonitis. Which of the following findings should the nurse expect?

Rigid abdomen

When providing dietary instruction to a patient with HTN, the RN would advise to restrict intake of which meat?

Roasted duck

Which of the following indicates the patient is experiencing an adverse effect of Hydrochlorothiazide?

Serum potassium value of 3.0 mEq/L

Which nursing instruction is emphasized safety for a patient who is newly prescribed an antihypertensive?

Sit on the edge of the chair and rise slowly

A nurse is teaching about disease management for a client who has type 1 diabetes mellitus. which statement made by the client indicates an understanding of the teaching?

"I give the insulin injections in my abdominal area"

A nurse is providing teaching about foot care for a client who has type 2 diabetes mellitus. which of the following statements by the client indicates an understanding of the teaching?

"I should buy new shoes later in the day"

A nurse is teaching about self- monitoring to a client who has type 1 diabetes mellitus. which of the following statements by the client indicates an understanding of the teaching?

"I will check my blood glucose every 4 hours when I am sick"

A nurse is teaching a client who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following statements by the client indicates an understanding of the teaching?

"I will feel shaky."

A nurse is teaching an older adult client who has diabetes mellitus about preventing the long-term complications of retinopathy and nephropathy. Which of the following instructions should the nurse include?

"Maintain stable blood glucose levels"

A nurse is providing discharge teaching to a client who has peripheral arterial disease (PAD) which of the following instructions should the nurse include in the teaching?

Adjust the thermostat so that the environment is warm

A patient with Type 1 Diabetes mellitus has a fingerstick blood glucose level of 258 mg/dL at bedtime. An order for sliding scale insulin exists. You should?

Administer the insulin as ordered

When checking a client's capillary refill, the nurse finds that the color returns in 10 seconds. The nurse should understand that this finding indicates which of the following?

Arterial insufficiency