S4 Unit 4 questions 2

A nurse assesses a client on the medical-surgical unit. Which statement made by the client alerts the nurse to assess the patient for hypothyroidism? "My sister has thyroid problems." "I seem to feel the heat more than other people." "Food just doesn't taste good without a lot of salt." "I am always tired, even with 12 hours of sleep."

"I am always tired, even with 12 hours of sleep." Clients with hypothyroidism usually feel tired or weak despite getting many hours of sleep. Most thyroid problems are not inherited, although they may occur in families. Heat intolerance is indicative of hyperthyroidism. Loss of taste is not a manifestation of hypothyroidism. The nurse would assess the client further for hypothyroidism.

A nurse cares for a client who has hypothyroidism as a result of Hashimotothyroiditis. The client asks, "How long will I need to take this thyroid medication?" How would the nurse respond? "You will need to take the thyroid medication until the goiter is completely gone." "Thyroiditis is cured with antibiotics. Then you won't need thyroid medication." "You'll need thyroid pills for life because your thyroid won't start working again." "When blood tests indicate normal thy

"You'll need thyroid pills for life because your thyroid won't start working again." Hashimoto thyroiditis results in a permanent loss of thyroid function. The client will need lifelong thyroid replacement therapy and will not be able to stop taking the medication.

A nurse is caring for an older adult receiving multiple packed red blood cell transfusions. Which assessment finding(s) indicate(s) possible transfusion circulatory overload? (Select all that apply.) Acute confusion Dyspnea Depression Hypertension Bradycardia Bounding pulse

Acute confusion Dyspnea Hypertension Bounding pulse Circulatory overload is the result of excessive body fluid which can cause signs and symptoms of heart failure including dyspnea, increased blood pressure, tachycardia (not bradycardia), and a bounding pulse. Dyspnea is caused by hypoxia which in older adults can cause acute confusion. Depression is not a common finding resulting from fluid overload.

A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. What action would the nurse take? Administration of oxygen via facemask Intravenous administration of 10% glucose Implementation of seizure precautions Administration of intravenous insulin

Administration of intravenous insulin The rapid, deep respiratory efforts of Kussmaul respirations are the body's attempt to reduce the acids produced by using fat rather than glucose for fuel. Only the administration of insulin will reduce this type of respiration by assisting glucose to move into cells and to be used for fuel instead of fat. The patient who is in ketoacidosis may not experience any respiratory impairment and therefore does not need additional oxygen. Giving the patient glucose would be contraindicated. The patient does not require seizure precautions.

The nurse is caring for a client with adrenal insufficiency. What priority physical assessment would the nurse perform? Respiratory assessment Skin assessment Neurologic assessment Cardiac assessment

Cardiac assessment The client who has adrenal insufficiency has hyperkalemia that can cause cardiac dysrhythmias. Therefore, the nurse would monitor the client's cardiovascular status through frequent assessments.

A nurse assesses a patient who is experiencing diabetic ketoacidosis (DKA). For which assessment findings would the nurse monitor the client? (Select all that apply.) Deep and fast respirations Decreased urine output Tachycardia Dependent pulmonary crackles Orthostatic hypotension

Deep and fast respirations Tachycardia Orthostatic hypotension DKA leads to dehydration, which is manifested by tachycardia and orthostatic hypotension. Usually, patients have Kussmaul respirations, which are fast and deep. Increased urinary output (polyuria) is severe. Because of diuresis and dehydration, peripheral edema and crackles do not occur.

The nurse is caring for a newly admitted older adult with DM II who has a blood glucose of 300 mg/dL (16.7 mmol/L), a urine output of 185 mL in the past 8 hours, and a blood urea nitrogen (BUN) of 44 mg/dL (15.7 mmol/L). What diabetic complication does the nurse suspect? Diabetic ketoacidosis (DKA) Severe hypoglycemia Chronic kidney disease (CKD) Hyperglycemic-hyperosmolar state (HHS)

Hyperglycemic-hyperosmolar state (HHS) The client most likely has diabetes mellitus type 2 and has a high blood glucose causing increased blood osmolarity and dehydration, as evidenced by an insufficient urinary output and increased BUN. Older adults are at the greatest risk for dehydration due to age-related physiologic changes.

A nurse teaches a client with hyperthyroidism. Which dietary modifications should the nurse include in this client's health teaching? (Select all that apply.) Increased carbohydrates Decreased fats Increased calorie intake Supplemental vitamins Increased proteins

Increased carbohydrates Increased calorie intake Increased proteins The client is hypermetabolic and has an increased need for carbohydrates, calories, and proteins. Proteins are especially important because the client is at risk for a negative nitrogen balance. There is no need to decrease fat intake or take supplemental vitamins.

A patient admitted with pneumonia has a total serum calcium level of 13.3 mg/dL. What should the nurse anticipate will be tested next? Calcitonin Catecholamine Thyroid hormone Parathyroid hormone

Parathyroid hormone Parathyroid hormone (PTH) is the major controller of blood calcium levels. Although calcitonin secretion is a counter mechanism to PTH, it does not play a major role in calcium balance.

The nurse is planning health teaching for a client starting on levothyroxine. What health teaching about this drug would the nurse include? The need to take the drug when the client feels fatigued and weak. The need to report chest pain and dyspnea when starting the drug. The need to check blood pressure and pulse every day. The need to rotate injection sites when giving self the drug.

The need to report chest pain and dyspnea when starting the drug. Levothyroxine is a replacement hormone for clients who have hypothyroidism and is taken orally for life. Vital signs do not have to be checked every day, but the client should report any chest pain and dyspnea when first starting the drug.

A nurse plans care for a client with a growth hormone deficiency. Which action would the nurse include in this client's plan of care? Avoid intramuscular medications. Place the client in protective isolation. Use a lift sheet to reposition the patient. Assist the client to dangle before rising.

Use a lift sheet to reposition the patient. In adults, growth hormone is necessary to maintain bone density and strength. Adults with growth hormone deficiency have thin, fragile bones. Avoiding IM medications, using protective isolation, and assisting the client as he or she moves from sitting to standing will not serve as safety measures when the client is deficient in growth hormone.

Which assessment finding(s) may indicate that a client may be experiencing a blood transfusion reaction? (Select all that apply.) a. Tachycardia b. Fever c. Bronchospasm d. Tachypnea e. Urticaria f. Hypotension

all

The nurse assesses a client with diabetic ketoacidosis. Which assessment finding would the nurse correlate with this condition? Increased rate and depth of respiration Extremity tremors followed by seizure activity Oral temperature of 102° F (38.9° C) Severe orthostatic hypotension

increased rr Ketoacidosis decreases the pH of the blood, stimulating the respiratory control areas of the brain to buffer the effects of increasing acidosis. The rate and depth of respiration are increased (Kussmaul respirations) in an attempt to excrete more acids by exhalation. Tremors, elevated temperature, and orthostatic hypotension are not associated with ketoacidosis.

Vasopressin (ADH)

raises blood pressure and makes kidneys conserve water

Normal calcium levels

8.5-10.5 mg/dL

A patient is scheduled in the outpatient clinic for blood cortisol testing. Which instruction should the nurse provide? "Avoid adding any salt to your foods for 24 hours before the test." "You will need to lie down for 30 minutes before the blood is drawn." "Come to the laboratory to have the blood drawn early in the morning." "Do not have anything to eat or drink before the blood test is obtained."

"Come to the laboratory to have the blood drawn early in the morning." Cortisol levels are usually drawn in the morning, when levels are highest.

Which question from the nurse during a patient interview will provide focused information about a possible thyroid disorder? "What methods do you use to help cope with stress?" "Have you experienced any blurring or double vision?" "Have you had a recent unplanned weight gain or loss?" "Do you have to get up at night to empty your bladder?"

"Have you had a recent unplanned weight gain or loss?" Because thyroid function affects metabolic rate, changes in weight may indicate hyperfunction or hypofunction of the thyroid gland. Nocturia, visual difficulty, and changes in stress level are associated with other endocrine disorders.

After teaching a client with acromegaly who is scheduled for an open transsphenoidal hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a need for further teaching? "I will no longer need to limit my fluid intake after surgery." "I am glad no visible incision will result from this surgery." "I hope I can go back to wearing size 8 shoes instead of size 12." "I will wear slip-on shoes after surgery to limit bending over."

"I hope I can go back to wearing size 8 shoes instead of size 12." Although removal of the tissue that is oversecreting hormones can relieve many symptoms of hyperpituitarism, skeletal changes and organ enlargement are not reversible. It will be appropriate for the client to drink as needed postoperatively and avoid bending over. The client can be reassured that the incision will not be visible.

The nurse is caring for a client who is starting on propylthiouracil for hyperthyroidism. What statement by the client indicates a need for further teaching? a. "I will let my provider know if I have weight gain and cold intolerance." "I will let my provider know if I have a metallic taste or stomach upset." "I will avoid crowds and other people who have infection." "I am aware that if the drug changes the color of my urine, I should stop it."

"I will let my provider know if I have a metallic taste or stomach upset." If the client's urine turns dark and/or the skin has a yellow appearance, the client may have possible liver toxicity from the drug. This is a serious adverse effect and needs to be reported to the primary health care provider after stopping the drug. If weight gain and cold intolerance occurs, then the client may need a lower dose of the drug. The drug should not cause GI distress or a metallic taste in his or her mouth.

After teaching a client who is recovering from an endoscopic transsphenoidal hypophysectomy, the nurse assesses the client's understanding. Which statement made by the client indicates a correct understanding of the teaching? "I will wear dark glasses to prevent sun exposure." "I'll keep food on upper shelves so I do not have to bend over." "I must wash the incision with saline and redress it daily." "I should cough and deep breathe every 2 hours while I am awake."

"I'll keep food on upper shelves so I do not have to bend over." After this surgery, the client must take care to avoid activities that can increase intracranial pressure. The client should avoid bending from the waist and should not bear down, cough, or lie flat. With this approach, there is no incision to clean and dress. Protection from sun exposure is not necessary after this procedure.

A nurse cares for a client with adrenal hyperfunction. The client screams at her husband, bursts into tears, and throws her water pitcher against the wall. She then tells the nurse, "I feel like I am going crazy." How would the nurse respond? "I will ask your doctor to order a mental health consult for you." "You feel this way because of your hormone levels." "Can I bring you information about support groups?" "I will close the door to your room and restrict visitors."

"You feel this way because of your hormone levels." Hypercortisolism can cause the client to have neurotic or psychotic behaviors. The client needs to know that these behavior changes do not reflect a true mental or behavioral health disorder and will resolve when therapy results in lower and steadier blood cortisol levels. The client needs to understand this effect and does not need a psychiatrist, support groups, or restricted visitors at this time.

A nurse assesses clients for potential endocrine dysfunction. Which client is at greatest risk for a deficiency of gonadotropin and growth hormone? A 36-year-old female who has used oral contraceptives for 5 years A 42-year-old male who experienced head trauma 3 years ago A 55-year-old female with a severe allergy to shellfish and iodine A 64-year-old male with adult-onset diabetes mellitus

A 42-year-old male who experienced head trauma 3 years ago Gonadotropin and growth hormone are anterior pituitary hormones. Head trauma is a common cause of anterior pituitary hypofunction. The other factors do not increase the risk of this condition.

A nurse assesses a client who is recovering from a subtotal thyroidectomy. On the first postoperative day before discharge, the client states, "I feel numbness and tingling around my mouth." What action does the nurse take? Offer mouth care. Loosen the dressing. Assess for muscle twitching. Ask the client orientation questions

Assess for muscle twitching. Numbness and tingling around the mouth or in the fingers and toes are manifestations of hypocalcemia, which could progress to cause tetany and seizure activity. The nurse would assess for muscle twitching and, if present, notify the surgeon or Rapid Response Team to give calcium gluconate or other IV calcium replacement.

The nurse is caring for clients on the medical-surgical unit. What action by the nurse will help prevent a client from having a type II hypersensitivity reaction? Administering steroids for a positive TB test Correctly identifying the client prior to a blood transfusion Keeping the client free of the offending agent Providing a latex-free environment for the client

Correctly identifying the client prior to a blood transfusion A classic example of a type II hypersensitivity reaction is a blood transfusion reaction. These can be prevented by correctly identifying the client and cross-checking the unit of blood to be administered. A positive type IV response is a positive TB test. Avoidance therapy is the cornerstone of treatment for a type IV hypersensitivity to substances that are known and can be avoided such as poison ivy and insect stings. Latex allergies are a type I hypersensitivity.

A nurse is preparing to administer a blood transfusion. What action is most important? Correctly identify client using two identifiers. Ensure that informed consent is obtained. Hang the blood product with Ringer's lactate. Stay with the client for the entire transfusion.

Ensure that informed consent is obtained. If the facility requires informed consent for transfusions, this action is most important because it precedes the other actions taken during the transfusion. Correctly identifying the client and blood product is a National Patient Safety Goal, and is the most important action after obtaining informed consent. Ringer's lactate is not used to transfuse blood. The nurse does not need to stay with the client for the duration of the transfusion.

The nurse is caring for a newly admitted client who is diagnosed with hyperglycemic-hyperosmolar state (HHS). What is the nurse's priority action at this time? Assess the client's blood glucose level. Monitor the client's urinary output every hour. Establish intravenous access to provide fluids. Give regular insulin per agency policy.

Establish intravenous access to provide fluids. The first priority in caring for a client with HHS is to increase blood volume to prevent shock or severe hypotension from dehydration. The nurse would monitor vital signs, urinary output, and blood glucose to determine if interventions were effective. Regular insulin is also indicated but not as the first priority action.

The nurse is caring for a client who has acromegaly. What physical change would the nurse expect to observe? Large hands and face Thin, dry skin Short height Truncal obesity

Large hands and face The client who has acromegaly has an excess of growth hormone as an adult and therefore has a large musculoskeletal structure that is readily observed.

When caring for an older client who has hypothyroidism, what assessment findings will the nurse expect? (Select all that apply.) Lethargy Diarrhea Low body temperature Tachycardia Slowed speech Weight gain

Lethargy Low body temperature Slowed speech Weight gain A client who has an underactive thyroid gland has a decreased metabolic rate, resulting in lethargy and lack of energy, weight gain, slowed speech, and decreased vital signs like a lowered body temperature. The client also typically has constipation (instead of diarrhea) due to slower peristalsis and bradycardia (instead of tachycardia).

A nurse is caring for a client with elevated triiodothyronine and thyroxine, and normal thyroid-stimulating hormone levels. What actions does the nurse take? (Select all that apply.) Administer levothyroxine. Administer propranolol. Monitor the apical pulse. Assess for Trousseau sign. Initiate telemetry monitoring.

Monitor the apical pulse. Initiate telemetry monitoring. The client's laboratory findings suggest that the client is experiencing hyperthyroidism. The increased metabolic rate can cause an increase in the client's heart rate, and the client should be monitored for the development of dysrhythmias. Placing the client on a telemetry monitor might also be a precaution. Levothyroxine is given for hypothyroidism. Propranolol is a beta blocker often used to lower sympathetic nervous system activity in hyperthyroidism. Trousseau sign is a test for hypocalcemia.

A nurse assesses a client with Cushing disease. Which assessment findings would the nurse expect? (Select all that apply.) Moon face Weight loss Hypotension Petechiae Muscle atrophy

Moon face Petechiae Muscle atrophy Clinical manifestations of Cushing disease include moon face, weight gain, hypertension, petechiae, and muscle atrophy.

A nurse cares for a client with a hypofunctioning anterior pituitary gland. Which hormones would the nurse expect to be decreased as a result? (Select all that apply.) Thyroid-stimulating hormone Vasopressin Follicle-stimulating hormone d. Calcitonine. Growth hormone

Thyroid-stimulating hormone Follicle-stimulating hormone Growth hormone Thyroid-stimulating hormone, follicle-stimulating hormone, and growth hormone all are secreted by the anterior pituitary gland. Vasopressin is secreted from the posterior pituitary gland. Calcitonin is secreted from the thyroid gland.

While assessing a client with Graves disease, the nurse notes that the client's temperature has risen 1° F (1° C). What does the nurse do first? Turn the lights down and shut the patient's door. Call for an immediate electrocardiogram (ECG). Calculate the client's apical-radial pulse deficit. Administer a dose of acetaminophen.

Turn the lights down and shut the patient's door. A temperature increase of 1° F (5/9° C) may indicate the development of thyroid storm, and the primary health care provider or RRT needs to be notified. But before notifying the provider, the nurse should first take measures to reduce environmental stimuli that increase the risk of cardiac complications. The nurse can then call for an ECG. The apical-radial pulse deficit would not be necessary, and acetaminophen is not needed because the temperature increase is due to thyroid activity.

A nurse assesses a client who has diabetes mellitus. Which arterial blood gas values would the nurse identify as potential ketoacidosis in this client?

low ph, HCO3, and CO2 When the lungs can no longer offset acidosis, the pH decreases to below normal. A client who has diabetic ketoacidosis would present with arterial blood gas values that show primary metabolic acidosis with decreased bicarbonate levels and a compensatory respiratory alkalosis with decreased carbon dioxide levels.

The nurse is caring for a client with acromegaly who is starting bromocriptine. What health teaching by the nurse about drug therapy will the nurse include? "Take this drug on an empty stomach first thing in the morning." "You will be starting on a high dose of the drug to ensure it will work." "You might experience an increase in blood pressure in about a week." "Seek medical attention immediately if you have chest pain and dizziness."

"Seek medical attention immediately if you have chest pain and dizziness." Bromocriptine should be started on a low dose and taken with food. The drug can cause decreased blood pressure, including orthostatic hypotension. Serious effects such as cardiac dysrhythmias, coronary artery spasms, and cerebrospinal leak can occur Therefore, the nurse teaches the client should seek medical attention if he or she experiences chest pain, dizziness, and watery nasal discharge.

A client is admitted with a possible diagnosis of diabetes insipidus (DI). What assessment findings would the nurse expect? (Select all that apply.) Hypotension Increased urinary output Concentrated urine Decreased thirst Poor skin turgor Bradycardia

Hypotension Increased urinary output Poor skin turgor The client who has DI has excessive urination and dehydration. Clients who are dehydrated have decreased blood pressure, increased pulse (tachycardia), and poor skin turgor. The urine is dilute with a low specific gravity.

A nurse is preparing to administer a packed red blood cell transfusion to an older adult. Understanding age-related changes, what alteration(s) in the usual protocol is (are) necessary for the nurse to implement? (Select all that apply.) Assess vital signs at least every 15 minutes. Avoid giving other IV fluids. Premedicate to prevent transfusion reaction. Transfuse smaller bags of blood. Transfuse each unit over 8 hours. Assess the client for fluid overload.

Assess vital signs at least every 15 minutes. Avoid giving other IV fluids. Assess the client for fluid overload. The older adult needs vital signs monitored as often as every 15 minutes for the duration of the transfusion because vital sign changes may be the only indication of a transfusion-related problem. To prevent fluid overload, the nurse obtains a prescription to hold other running IV fluids during the transfusion and assesses the client frequently for signs and symptoms of overload. The other options are not correct.

A nurse assesses a client who is recovering from a subtotal thyroidectomy and observes the development of stridor. What is the priority action for the nurse to take? Apply oxygen via nasal cannula at 2 L/min. Document the finding and assess the client hourly. Place the client in high-Fowler position in the bed. Contact the Rapid Response Team and prepare for intubation.

Contact the Rapid Response Team and prepare for intubation. Stridor on exhalation is a hallmark of respiratory distress, usually caused by obstruction resulting from edema. The nurse should prepare to assist with emergency intubation or tracheostomy while notifying the Rapid Response Team. Stridor is an emergency situation; therefore, reassuring the client, documenting, and reassessing in an hour do not address the urgency of the situation. Oxygen should be applied, but this action will not keep the airway open.

The nurse is caring for a client who is diagnosed with diabetes insipidus (DI). For what common complication will the nurse monitor? Hypertension Bradycardia Dehydration Pulmonary embolus

Dehydration The client who has DI has fluid loss through excessive urination. Decreased fluid volume, or dehydration, is manifested by tachycardia, hypotension, and possibly elevated temperature. Pulmonary embolism (PE) could possible as a clot in the lower extremity (caused by dehydration) could fragment and travel to the lungs

A nurse plans care for a client with hypothyroidism. Which priority problem does the nurse address first for this client? Heat intolerance Body image problems Depression and withdrawal Obesity and water retention

Depression and withdrawal Hypothyroidism causes many problems in psychosocial functioning. Depression is the most common reason for seeking medical attention. Memory and attention span may be impaired. The client's family may have great difficulty accepting and dealing with these changes. The client is often unmotivated to participate in self-care. Lapses in memory and attention require the nurse to ensure that the patient's environment is safe. Heat intolerance is seen in hyperthyroidism. Body image problems and weight issues do not take priority over mental status and safety.

A nurse assesses a client who is prescribed levothyroxine for hypothyroidism. Which assessment finding alerts the nurse that drug therapy is effective? Thirst is recognized and fluid intake is appropriate. Weight has been the same for 3 weeks. Total white blood cell count is 6000 cells/mm3 (6 109/L). Heart rate is 76 beats/min and regular.

Heart rate is 76 beats/min and regular. Hypothyroidism decreases body functioning and can result in effects such as bradycardia, confusion, and constipation. If a client's heart rate is bradycardic while on thyroid hormone replacement, this is an indicator that the replacement may not be adequate. Conversely, a heart rate above 100 beats/min may indicate that the client is receiving too much of the thyroid hormone. Thirst, fluid intake, weight, and white blood cell count do not represent a therapeutic response to this medication.

A nurse reviews the chart and new prescriptions for a client with diabetic ketoacidosis: low BP tachy RR 28 UO 20 ml/h K 2.6 orders: potassium IV and increase IVF What action would the nurse take? Administer the potassium and then consult with the primary health care provider about the fluid prescription. Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription. Administer the potassium first before increasing the infusion flow r

Increase the intravenous rate and then consult with the primary health care provider about the potassium prescription. The client is acutely ill and is severely dehydrated and hypokalemic, requiring more IV fluids and potassium. However, potassium would not be infused unless the urine output is at least 30 mL/hr. The nurse would first increase the IV rate and then consult with the primary health care provider about the potassium.

A young adult patient who is being seen in the clinic has excessive secretion of the anterior pituitary hormones. Which laboratory test result should the nurse expect? Increased urinary cortisol Decreased serum thyroxine Elevated serum aldosterone Low urinary catecholamines

Increased urinary cortisol Increased secretion of adrenocorticotropic hormone (ACTH) by the anterior pituitary gland will lead to an increase in serum and urinary cortisol levels. An increase, rather than a decrease, in thyroxine level would be expected with increased secretion of thyroid-stimulating hormone (TSH) by the anterior pituitary. The anterior pituitary does not control aldosterone and catecholamine levels.

A nurse cares for a client who presents with bradycardia secondary to hypothyroidism. Which medication does the nurse prepare to administer? Atropine sulfate Levothyroxine Propranolol Epinephrine

Levothyroxine The treatment for bradycardia from hypothyroidism is to treat the hypothyroidism using levothyroxine. If the heart rate were so slow that it became an emergency, then atropine or epinephrine might be an option for short-term management. Propranolol is a beta blocker and would be contraindicated for a client with bradycardia.

The nurse is caring for a client who has possible hypothyroidism. What possible risk factors can cause this health problem? (Select all that apply.) Lithium drug therapy Thyroid cancer Autoimmune thyroid disease Iodine deficiency Laryngitis Pituitary tumors

Lithium drug therapy Thyroid cancer Autoimmune thyroid disease Iodine deficiency Pituitary tumors

A nurse teaches a client with Cushing disease. Which dietary requirements would the nurse include in this client's health teaching? (Select all that apply.) Low calcium Low carbohydrate Low protein Low calories Low sodium

Low carbohydrate Low calories Low sodium The client with Cushing disease has weight gain, muscle loss, hyperglycemia, and sodium retention. Dietary modifications need to include reduction of carbohydrates and total calories to prevent or reduce the degree of hyperglycemia. Sodium retention causes water retention and hypertension. Clients are encouraged to restrict their sodium intake moderately. Clients often have bone density loss and need more calcium. Increased protein intake will help decrease muscle loss.

A nurse assesses a client with diabetes mellitus. Which assessment finding would alert the nurse to decreased kidney function in this client? Urine specific gravity of 1.033 Presence of protein in the urine Elevated capillary blood glucose level Presence of ketone bodies in the urine

Presence of protein in the urine Renal dysfunction often occurs in the client with diabetes. Proteinuria is a result of renal dysfunction. Specific gravity is elevated with dehydration. Elevated capillary blood glucose levels and ketones in the urine are consistent with diabetes mellitus but are not specific to renal function.

A nurse reviews the laboratory results of a client who is receiving intravenous insulin. Which would alert the nurse to intervene immediately? Serum chloride level of 98 mEq/L (98 mmol/L) Serum calcium level of 8.8 mg/dL (2.2 mmol/L) Serum sodium level of 132 mEq (132 mmol/L) Serum potassium level of 2.5 mEq/L (2.5 mmol/L)

Serum potassium level of 2.5 mEq/L (2.5 mmol/L) Insulin activates the sodium-potassium ATPase pump, increasing the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. In hyperglycemia, hypokalemia can also result from excessive urine loss of potassium.

A nurse plans care for a client with hyperparathyroidism. Which intervention does the nurse include in this client's plan of care? Use a lift sheet to assist the client with position changes in bed. Ask the client to ambulate in the hallway twice a day. Provide the client with a soft-bristled toothbrush for oral care. Instruct the assistive personnel to strain the patient's urine for stones.

Use a lift sheet to assist the client with position changes in bed. Hyperparathyroidism causes increased resorption of calcium from the bones, increasing the risk for pathologic fractures. Using a lift sheet when moving or positioning the client, instead of pulling on the client, reduces the risk of bone injury. Hyperparathyroidism can cause kidney stones, but not every client will need to have urine strained. The priority is preventing injury. Ambulating in the hall and using a soft toothbrush are not specific interventions for this patient.

A client is being treated for diabetes insipidus (DI) with synthetic vasopressin (desmopressin). What is the priority health teaching that the nurse provides regarding drug therapy? The need to check the client's urinary specific gravity. The need to take blood pressure at least twice a day. The need to monitor blood glucose every day. The need to weigh every day and report weight gain.

The need to weigh every day and report weight gain. The client with DI who takes lifelong hormone replacement will need to report significant weight gain to monitor for water toxicity. Water toxicity causes headache, vomiting, and acute confusion.

The nurse is caring for a client receiving a unit of whole blood. Which nursing action(s) is (are) appropriate regarding infusion administration. (Select all that apply.) Use a dedicated filtered blood administration set. Stay with the client for the first 15 to 20 minutes of the infusion. Infuse the blood over a 30-minute period of time. Monitor and document vital signs per agency policy. Use a 21-gauge or smaller catheter to administer the blood. Infuse the transfusion with intravenous normal

Use a dedicated filtered blood administration set. Stay with the client for the first 15 to 20 minutes of the infusion. Monitor and document vital signs per agency policy. Infuse the transfusion with intravenous normal saline. Blood administration requires a dedicated and filtered intravenous set and a larger catheter or needle due to the viscosity of the infusion. Normal saline is the only IV fluid that is compatible with blood. Vital signs are frequently monitored and documented while the client is carefully assesses for signs and symptoms of a blood transfusion reaction, usually within the first 15 to 20 minutes. One unit of blood is administered in no less than 60 minutes.

The nurse is preparing to administer a blood transfusion. Which action(s) by the nurse is (are) most appropriate? (Select all that apply.) a. Hang the blood product using normal saline and a filtered tubing set. Take a full set of vital signs prior to starting the blood transfusion. Tell the client that someone will remain at the bedside for the first 5 minutes. Use gloves to start the client's IV if needed and to handle the blood product. Verify the client's identity, and checking blood com

a. Hang the blood product using normal saline and a filtered tubing set. Take a full set of vital signs prior to starting the blood transfusion. Use gloves to start the client's IV if needed and to handle the blood product. Correct actions prior to beginning a blood transfusion include hanging the product with saline and the correct filtered blood tubing, taking a full set of vital signs prior to starting, and using gloves. Someone stays with the client for the first 15 to 20 minutes of the transfusion. Two registered nurses must verify the client's identity and blood compatibility.