ADN 120 Unit 1 Thermoregulation, Fluid & Electrolytes and Glucose Regulation
When planning care for a diabetic patient with microalbuminuria, it is important to include which goal to reduce the progression to renal failure? Decrease the total percentage of calories from carbohydrates Decrease the total percentage of calories from fruits Decrease the total percentage of calories from proteins Decrease the total percentage of daily caloric intake
Decrease the total percentage of calories from proteins (Restriction of dietary protein to 0.8 g/kg body weight per day is recommended for clients with microalbuminuria to reduce the progression to renal failure. All other choices can increase blood glucose and total body weight but are not specific for progression to renal failure.)
The patient is receiving tube feedings due to a jaw surgery. What change in assessment findings should prompt the nurse to request an order for serum sodium concentration? Development of ankle or sacral edema Increased skin tenting and dry mouth Postural hypotension and tachycardia Decreased level of consciousness
Decreased level of consciousness (Tube feedings pose a risk for hypernatremia unless adequate water is administered between tube feedings. Hypernatremia causes the level of consciousness to decrease. The serum sodium concentration is a laboratory measure for osmolality imbalances, not ECV imbalances. Edema is a sign of ECV excess, not hypernatremia. Skin tenting, dry mouth, postural hypotension, and tachycardia all can be signs of ECV deficit.)
A patient has a tumor that secretes excessive antidiuretic hormone (ADH). He is confused and lethargic. His partner wants to know how a change in blood sodium can cause these symptoms. What should the nurse teach the patient's partner? Decreased sodium in the blood causes the blood volume to decrease so that not enough oxygen reaches the brain. Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. Increased sodium in the blood causes the blood volume to increase so that too much oxygen reaches the brain. Increased sodium in the blood causes brain cells to shrivel so that they do not work as effectively.
Decreased sodium in the blood causes brain cells to swell so that they do not work as effectively. (The normal action of ADH is renal reabsorption of water, which dilutes the blood. Excessive ADH causes hyponatremia, which is manifested by a decreased level of consciousness because the osmotic shift of water into the brain cells impairs their function. Hyponatremia does not decrease the blood volume. Answers that include increased sodium in the blood are incorrect because ADH excess causes hyponatremia rather than hypernatremia.)
A client presents to the emergency department with weakness and dizziness. The blood pressure is 90/60 mm Hg, pulse is 92 and weak, and body weight reflects a 3-pound (1.4 kilogram) loss in two days. The weather has been hot. Which condition should the nurse conclude is the priority for this client? Deficient fluid volume Impaired skin integrity Inadequate nutritional intake Decreased participation in activities
Deficient fluid volume (The low blood pressure indicates hypovolemia, the increased pulse is an attempt to maintain adequate oxygenation of tissues, and the rapid weight loss reflects loss of body fluid. Although impaired skin integrity is a concern with dehydration, it is not the priority. The rapid weight loss reflects a loss of fluid, not a loss of body tissue. Although the client may need assistance with activities, an inadequate intake of fluid has caused the client's dehydration, which is a serious medical problem that needs to be treated immediately.)
A client's temperature is 100.4° F (38° C) 12 hours after a spontaneous vaginal birth. What does the nurse suspect is the cause of the increased temperature? Mastitis Dehydration Puerperal infection Urinary tract infection
Dehydration (A client's temperature may be elevated to 100.4° F (38° C) during the first 24 hours after delivery because of dehydration resulting from the exertion and stress of labor. Mastitis usually develops after breastfeeding is established and the milk supply is present. Puerperal infection usually begins with a fever of 100.4° F (38 °C) or higher on 2 successive days, excluding the first 24 hours after delivery. Urinary tract infection usually becomes evident later in the postpartum period.)
A client's breath has a sweet, fruity odor. Which condition is likely affecting this client? Gum disease Uremic acidosis Diabetic acidosis Infection inside a cast
Diabetic acidosis (A client with diabetic acidosis has a sweet, fruity odor to the breath. Gum disease is marked by halitosis. A stale urine smell indicates uremic acidosis. An infection inside a cast is accompanied by a musty odor of the casted body part.)
A nurse is formulating a teaching plan for a client recently diagnosed with type 2 diabetes. What interventions should the nurse include to decrease the risk of complications? Select all that apply. Examine the feet daily Wear well-fitting shoes Perform regular exercise Powder the feet after showering Visit the primary healthcare provider weekly Test bathwater with the toes before bathing
Examine the feet daily Wear well-fitting shoes Perform regular exercise (Clients with diabetes often have peripheral neuropathies and are unaware of discomfort or pain in the feet; the feet should be examined every night for signs of trauma. Well-fitting shoes prevent pressure and rubbing that can cause tissue damage and the development of ulcers. Daily exercise increases the uptake of glucose by the muscles and improves insulin use. Powdering the feet after showering may cause a pastelike residue between the toes that may macerate the skin and promote bacterial and fungal growth. Generally, visiting the primary healthcare provider weekly is unnecessary. Clients with diabetes often have peripheral neuropathy and are unable to accurately evaluate the temperature of bathwater, which can result in burns if the water is too hot.)
The home health nurse should assess a patient who has chronic diarrhea for which fluid and electrolyte imbalances? Select all that apply. Extracellular fluid volume (ECV) excess Extracellular fluid volume (ECV) deficit Hypokalemia Hyperkalemia Hypocalcemia Hypercalcemia
Extracellular fluid volume (ECV) deficit Hypokalemia Hypocalcemia (Chronic diarrhea has a high risk of causing ECV deficit, hypokalemia, and hypocalcemia because it increases the fecal output of sodium-containing fluid, potassium, and calcium. Unless the intake of these substances increases appropriately, imbalances will occur. Excesses of ECV, potassium, and calcium are not likely, because the ECV, potassium, and calcium are being removed from the body.)
Which parts of the body assessed by the nurse would confirm a diagnosis of frostbite? Select all that apply. Axilla Fingers Ear lobes Forehead Upper thorax
Fingers Ear lobes (Areas particularly susceptible to frostbite are the fingers, toes, and earlobes. These parts of the body should be assessed to determine frostbite. The axilla is generally used to assess the body temperature; this site is used to diagnose a fever. The forehead and upper thorax are assessed to detect diaphoresis.)
The clinical findings of a client with diabetes mellitus show decreased glucose tolerance. Which complication is anticipated in the client? Cystitis Thin and dry skin Decreased bone density Frequent yeast infections
Frequent yeast infections (Decreased glucose tolerance may cause frequent yeast infections, but it is not associated with the risk of cystitis, thin and dry skin, and decreased bone density. The risk of cystitis, thin and dry skin, and decreased bone density are due to decreased ovarian production of estrogen.)
The nurse instructs a patient with type 1 diabetes mellitus to avoid which of the following drugs while taking insulin? Furosemide (Lasix) Dicumarol (Bishydroxycoumarin) Reserpine (Serpasil) Cimetidine (Tagamet)
Furosemide (Lasix) (Furosemide is a loop diuretic and can increase serum glucose levels; its use is contraindicated with insulin. Dicumarol, an anticoagulant; reserpine, an anti-hypertensive; and cimetidine, an H2 receptor antagonist, do not affect blood glucose levels.)
Four hours after surgery, the blood glucose level of a client who has type 1 diabetes is elevated. What intervention should the nurse implement? Administer an oral hypoglycemic Institute urine glucose monitoring Give supplemental doses of regular insulin Decrease the rate of the intravenous infusion
Give supplemental doses of regular insulin (The blood glucose level needs to be reduced; regular insulin begins to act in 30 to 60 minutes. The client has type 1, not type 2, diabetes, and an oral hypoglycemic will not be effective. Blood glucose levels are far more accurate than urine glucose levels. The rate may be increased because polyuria often accompanies hyperglycemia.)
A nurse is caring for a school-aged child with type 1 diabetes. There have been problems maintaining euglycemia. What laboratory test does the nurse expect to be prescribed that will reveal the effectiveness of the diabetic regimen over time? Serum glucose Glucose tolerance Fasting blood sugar Glycosylated hemoglobin
Glycosylated hemoglobin (HgbA1C) (The glycosylated hemoglobin test provides an accurate long-term index of the average blood glucose level for the 100 to 120 days before the test; the test is not affected by short-term variations. A result of less than 8% for this child indicates that the diabetic regimen is effective. Serum glucose reflects short-term (hours) variations in blood glucose. Glucose tolerance reveals carbohydrate metabolism in response to a glucose load. Fasting blood sugar is a screening test to rule out diabetes mellitus.)
An older adult with a history of diabetes reports giddiness, excessive thirst, and nausea. During an assessment, the nurse notices the client's body temperature as 113° F. Which condition does the nurse suspect in the client? Heat stroke Heat exhaustion Accidental hypothermia Malignant hyperthermia
Heat stroke (Older adults are more at a risk of heat stroke. Symptoms of heat stroke include giddiness, excessive thirst, nausea, and increased body temperature. Heat exhaustion is indicated by a fluid volume deficient. Heat exhaustion occurs when profuse diaphoresis results in excess water and electrolyte loss. Accidental hypothermia usually develops gradually and goes unnoticed for several hours. When the skin temperature drops below 95° F, the client suffers from uncontrolled shivering, memory loss, depression, and poor judgment. Malignant hyperthermia is an adverse effect of inhalational anesthesia that is indicated by a sudden rise in body temperature in intraoperative or postoperative clients.)
The nurse tells a client undergoing diuretic therapy to avoid working in the garden on hot summer days. What condition is the nurse trying to prevent in this client? Frostbite Heatstroke Hypothermia Hyperthermia
Heatstroke (Clients undergoing diuretic therapy are at risk of heatstroke when exposed to temperatures higher than 40° C. Frostbite occurs when the body is exposed to ice-cold temperatures. Hypothermia is a condition in which the skin temperature drops below 36° C. Hyperthermia occurs when the body is exposed to temperatures higher than 38.5° C.)
A school-aged child with type 1 diabetes is admitted to the pediatric unit in ketoacidosis. What sign of ketoacidosis does the nurse expect to identify when assessing the child? Sweating Hyperpnea Bradycardia Hypertension
Hyperpnea (Deep, rapid breathing (hyperpnea) is an attempt by the respiratory system to eliminate excess carbon dioxide; it is a compensatory mechanism associated with metabolic acidosis. Sweating is a physiological response to hypoglycemia. Tachycardia, not bradycardia, results from the hypovolemia caused by the polyuria associated with ketoacidosis. Hypotension, not hypertension, may result from the decreased vascular volume caused by the polyuria associated with ketoacidosis.)
It is most important for the nurse to include which risk factors in a teaching plan associated with the development of type 2 diabetes mellitus? Select all that apply. Hypertension History of pancreatic trauma Weight gain of 30 pounds during pregnancy Body mass index greater than 25 kg/m Triglyceride levels between 150 and 200 mg/dL Delivery of a 4.99-kg baby
Hypertension Body mass index greater than 25 kg/m Delivery of a 4.99-kg baby (Risk factors for type 2 diabetes include habitual inactivity, hypertension, delivery of a baby weighing over 9 pounds, a history of vascular disease, a body mass index greater than 25 kg/m, and triglyceride levels over 200 mg/dL.)
A patient has been having frequent liquid diarrhea for the last 24 hours. A stool sample was sent to the laboratory to confirm possible Clostridium difficile infection. The nurse should monitor the patient for which electrolyte imbalance? Dehydration Hypokalemia Hyponatremia Hypocalcemia
Hypokalemia (Potassium re-absorption primarily occurs through the renal system. However, approximately 10% of potassium regulation occurs in the gut. Hypokalemia can result when clients experience significant diarrhea.)
A nurse is caring for a client with endocrine problems. Which lab finding will alert the nurse that aldosterone will be released? Hypokalemia Hypoglycemia Hyponatremia Hypochloremia
Hyponatremia (Hyponatremia stimulates the secretion of aldosterone. Hypoglycemia inhibits the secretion of insulin. Hyperkalemia, not hypokalemia, stimulates the secretion of aldosterone. Hypochloremia is associated with increased levels of antidiuretic hormone.)
A client has been admitted with a diagnosis of intractable vomiting and can only tolerate sips of water. The initial blood work shows a sodium level of 122 mEq/L (122 mmol/L) and a potassium level of 3.6 mEq/L (3.6 mmol/L). Based on the lab results and symptoms, what is the client experiencing? Hypernatremia Hyponatremia Hyperkalemia Hypokalemia
Hyponatremia (The normal range for serum sodium is 135 to 145 mEq/L (135 to 145 mmol/L), and for serum potassium it is 3.5 to 5 mEq/L (3.5 to 5 mmol/L). Vomiting and use of diuretics, such as furosemide (Lasix), deplete the body of sodium. Without intervention, symptoms of hyponatremia may progress to include neurologic symptoms such as confusion, lethargy, seizures, and coma. Hypernatremia results when serum sodium is greater than 145 mEq/L (145 mmol/L); hyperkalemia results when serum potassium is greater than 5.0 mEq/L (5.0 mmol/L); hypokalemia results when serum potassium is less than 3.5 mEq/L (3.5 mmol/L).)
After surgical clipping of a ruptured cerebral aneurysm, a client develops the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). What manifestations are exhibited with excessive levels of antidiuretic hormone? Increased blood urea nitrogen (BUN) and hypotension Hyperkalemia and poor skin turgor Hyponatremia and decreased urine output Polyuria and increased specific gravity of urine
Hyponatremia and decreased urine output (Antidiuretic hormone (ADH) causes water retention, resulting in a decreased urine output and dilution of serum electrolytes. Blood volume may increase, causing hypertension. Diluting the nitrogenous wastes in the blood decreases rather than increases the BUN. Water retention dilutes electrolytes. The client is overhydrated rather than underhydrated, so turgor is not poor. ADH acts on the nephron to cause water to be reabsorbed from the glomerular filtrate, leading to reduced urine volume. The specific gravity of urine is elevated as a result of increased concentration.)
A client with a head injury underwent a physical examination. The nurse observes that the client's temperature assessments do not correspond with the client's condition. An injury to which part of the brain may be the reason for this condition? Pons Medulla Thalamus Hypothalamus
Hypothalamus (The hypothalamus controls the body temperature. Damage to the hypothalamus may cause abnormalities in the body temperature values during a physical assessment. The pons is responsible for maintaining level of consciousness. The medulla controls heart rate and breathing. The thalamus performs motor and sensory functions.)
Which is the first sign that would help the nurse in diagnosing malignant hyperthermia in a client? Abnormal rapid heart rate Abnormal rapid breathing Increased body temperature Increased expired carbon dioxide
Increased expired carbon dioxide (The first sign of malignant hyperthermia is increased expired carbon dioxide, caused by an abnormal and continuous contraction of the skeletal muscles. Due to metabolic changes in the skeletal muscles, there may be abnormal rapid breathing (tachypnea) and abnormal rapid heart rate (tachycardia), but it is not considered the first sign of malignant hyperthermia. Increased body temperature is often late to appear during malignant hyperthermia.)
A client with a history of hypothyroidism reports giddiness, excessive thirst, and nausea. Which parameter assessed by the nurse confirms the diagnosis as heat stroke? Increased heart rate Increased blood pressure Decreased respiratory rate Increased circulatory damage
Increased heart rate (Prolonged exposure to the sun or a high environmental temperature overwhelms the body's heat-loss mechanisms. These conditions cause heat stroke, which manifests as giddiness, excessive thirst, and nausea. An increased heart rate (HR) characterizes a heat stroke. A low blood pressure (BP), increased respiratory rate, and increased circulatory and tissue damage are not indicators of heat stroke.)
What clinical indicator will the nurse most likely identify when assessing a patient with pyrexia? Dyspnea Precordial pain Increased pulse rate Elevated blood pressure
Increased pulse rate (The pulse rate increases to meet increased tissue demands for oxygen in the febrile state. Fever may increase but does not cause difficulty in breathing. Pain is not related to fever. Blood pressure is not necessarily elevated in fever.)
A diabetic patient is brought into the emergency department unresponsive. The arterial pH is 7.28. Besides the blood pH, which clinical manifestation is seen in uncontrolled diabetes mellitus and ketoacidosis? Oral temperature of 38.9° Celsius Severe orthostatic hypotension Increased rate and depth of respiration Extremity tremors followed by seizure activity
Increased rate and depth of respiration (Ketoacidosis decreases the pH of the blood, stimulating the respiratory control area of the brain to buffer the effects of the increasing acidosis. The rate and depth of respirations are increased (Kussmaul's respirations) to excrete more acids by exhalation.)
The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? Raise bed side rails due to potential decreased level of consciousness and confusion. Examine sacral area and patient's heels for skin breakdown due to potential edema. Establish seizure precautions due to potential muscle twitching, cramps, and seizures. Institute fall precautions due to potential postural hypotension and weak leg muscles.
Institute fall precautions due to potential postural hypotension and weak leg muscles. (Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures.)
The nurse is admitting an older adult with decompensated congestive heart failure. The nursing assessment reveals adventitious lung sounds, dyspnea, and orthopnea. The nurse should question which doctor's order? Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr Furosemide (Lasix) 20 mg PO now Oxygen via face mask at 8 L/min KCl 20 mEq PO two times per day
Intravenous (IV) 500 mL of 0.9% NaCl at 125 mL/hr (A patient with decompensated heart failure has extracellular fluid volume (ECV) excess. The IV of 0.9% NaCl is normal saline, which should be questioned because it would expand ECV and place an additional load on the failing heart. Diuretics such as furosemide are appropriate to decrease the ECV during heart failure. Increasing the potassium intake with KCl is appropriate, because furosemide increases potassium excretion. Oxygen administration is appropriate in this situation of near pulmonary edema from ECV excess.)
Based on the nurse's assessment of a diabetic patient, which finding indicates the need for avoidance of exercise at this time? Ketone bodies in the urine Blood glucose level of 155 mg/dL Pulse rate of 66 beats per minute Weight gain of 1 pound over the previous week's weight
Ketone bodies in the urine (Exercise would lead to further elevations in blood glucose levels due to inadequate insulin to promote intracellular glucose transport and uptake. Assessing for ketones in the urine may indicate insulin deficiency.)
A patient has newly diagnosed hyperparathyroidism. What should the nurse expect to find during an assessment at the beginning of the nursing shift? Lethargy and constipation from hypercalcemia Positive Trousseau's sign from hypercalcemia Lethargy and constipation from hypocalcemia Positive Trousseau's sign from hypocalcemia
Lethargy and constipation from hypercalcemia (Parathyroid hormone (PTH) shifts calcium from the bones into the extracellular fluid (ECF). Excessive PTH causes hypercalcemia, which is manifested by lethargy and constipation. A positive Trousseau's sign is characteristic of hypocalcemia rather than hypercalcemia. Answers that indicate hypocalcemia are not correct, because PTH moves calcium into the ECF.)
A nurse is teaching a 15-year-old adolescent with newly diagnosed type 1 diabetes about self-care. What is the primary long-term goal this nurse and client should agree on? Maintaining normoglycemia Complying with the diabetic diet Adhering to an exercise program Developing a nonstressful lifestyle
Maintaining normoglycemia (Maintaining normoglycemia is a realistic goal because it decreases the risk of complications such as neuropathy, retinopathy, and atherosclerosis. A regimen of insulin, exercise, and diet will help the adolescent achieve this goal. Compliance with a diabetic diet is an objective because it will help the adolescent achieve the long-term goal; diet alone is insufficient to achieve normoglycemia. Adherence to an exercise program is an objective because it will help the adolescent achieve the long-term goal; exercise alone is insufficient to achieve normoglycemia. Development of a nonstressful lifestyle is a worthwhile goal, but it is not realistic.)
The nurse recognizes which patient as having the greatest risk for undiagnosed diabetes mellitus? Young white man Middle-aged African-American man Young African-American woman Middle-aged Native American woman
Middle-aged Native American woman (The highest incidence of diabetes in the United States occurs in Native Americans. With age, the incidence of diabetes increases in all races and ethnic groups.)
The nurse provides education about signs and symptoms of hypoglycemia to a client with newly diagnosed type 1 diabetes. The nurse concludes that the teaching was effective when the client acknowledges the need to drink orange juice when experiencing which symptoms? Nervous and weak Thirsty with a headache Flushed and short of breath Nausea and abdominal cramps
Nervous and weak (Nervousness and weakness are the most commonly reported symptoms of hypoglycemia and are related to increased sympathetic nervous system activity. Feeling flushed and short of breath are adaptations of hyperglycemia. Being thirsty, having a headache, being nauseated, or having abdominal cramps are symptoms of hyperglycemia.)
A nurse is planning an evening snack for a child receiving NPH insulin. What is the reason for this nursing action? It encourages the child to stay on the diet. Energy is needed for immediate utilization. Extra calories will help the child gain weight. Nourishment helps counteract late insulin activity.
Nourishment helps counteract late insulin activity. (A bedtime snack is needed for the evening. NPH insulin is intermediate-acting insulin, which peaks 4 to 12 hours later and lasts for 18 to 24 hours. Protein and carbohydrate ingestion before sleep prevents hypoglycemia during the night when the NPH is still active. The snack is important for diet-insulin balance during the night, not encouragement. There are no data to indicate that extra calories are needed; a bedtime snack is routinely provided to help cover intermediate-acting insulin during sleep. The snack must contain mainly protein-rich foods, not simple carbohydrates, to help cover the intermediate-acting insulin during sleep.)
The patient with which diagnosis should have the highest priority for teaching regarding foods that are high in magnesium? Severe hemorrhage Diabetes insipidus Oliguric renal disease Adrenal insufficiency
Oliguric renal disease (When renal excretion is decreased, magnesium intake must be decreased also, to prevent hypermagnesemia. The other conditions are not likely to require adjustment of magnesium intake.)
A 25-year-old student has been taken to an urgent care clinic because of dehydration. She says she has had "the flu," with vomiting and diarrhea "all night" and has had very little to eat or drink. She says the GI symptoms have subsided, but she feels weak. The nurse expects which type of rehydration to occur? IV fluid replacement Oral rehydration therapy with tea Oral rehydration therapy with water Oral rehydration therapy with a solution containing glucose and electrolytes
Oral rehydration therapy with a solution containing glucose and electrolytes (Whenever possible, fluids are replaced by the oral route. When dehydration is severe or life threatening, or the patient is not able to tolerate oral fluids, IV fluid replacement is needed. Oral rehydration therapy (ORT) is a cost-effective way to replace fluids for the patient with dehydration. Specifically formulated solutions containing glucose and electrolytes are absorbed even when the patient is vomiting or has diarrhea.)
The serum potassium level of a client who has diabetic ketoacidosis is 5.4 mEq/L (5.4 mmol/L). What would the nurse expect to see on the ECG tracing monitor? Abnormal P waves and depressed T waves Peaked T waves and widened QRS complexes Abnormal Q waves and prolonged ST segments Peaked P waves and an increased number of T waves
Peaked T waves and widened QRS complexes (Potassium is the principal intracellular cation, and during ketoacidosis it moves out of cells into the extracellular compartment to replace potassium lost as a result of glucose-induced osmotic diuresis; overstimulation of the cardiac muscle results. The T wave is depressed in hypokalemia. Initially, the QT segment is short, and as the potassium level rises, the QRS complex widens. P waves are abnormal because the PR interval may be prolonged and the P wave may be lost; however, the T wave is peaked, not depressed. The ST segment becomes depressed. The PR interval is prolonged, and the P wave may be lost. QRS complexes and thus T waves become irregular, and the rate does not necessarily change.)
During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? Impaired cognition Occupational exposure Physical agility Temperature extremes
Physical agility (Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation.)
The nurse should institute which precaution for the hypoglycemic patient receiving intramuscular glucagon due to an inability to swallow the oral form? Elevate the head of the bed. Have a padded tongue blade at the bedside. Position the client face down or in a side-lying position. Apply pressure and massage the injection site for 5 minutes
Position the client face down or in a side-lying position. (Intramuscular injection of glucagon often causes vomiting, increasing the patient's risk for aspiration. Elevating the head of the bed, instituting the use of a padded tongue blade, or applying pressure at or massaging injection site is not a safe nursing practice.)
The nurse assessed four patients at the beginning of the shift. Which finding should the nurse report most urgently to the physician? Swollen ankles in patient with compensated heart failure Positive Chvostek's sign in patient with acute pancreatitis Dry mucous membranes in patient taking a new diuretic Constipation in patient who has advanced breast cancer
Positive Chvostek's sign in patient with acute pancreatitis (Positive Chvostek's sign indicates increased neuromuscular excitability, which can progress to dangerous laryngospasm or seizures and thus needs to be reported first. The other assessment findings are less urgent and need further assessment. Bilateral ankle edema is a sign of ECV excess, and follow-up is needed, but the situation is not immediately life-threatening. Dry mucous membranes in a patient taking a diuretic may be associated with ECV deficit; however, additional assessments of ECV deficit are required before reporting to the physician. Constipation has many causes, including hypercalcemia and opioid analgesics, and it needs action, but not as urgently as a positive Chvostek's sign.)
While monitoring a patient who has fluid overload, the nurse would be most concerned about which assessment finding? Bounding pulse Neck vein distention Pitting edema in the feet Presence of crackles in the lungs
Presence of crackles in the lungs (Fluid overload may lead to pulmonary edema and heart failure. Any patient with fluid overload, regardless of age, is at risk for these complications. Older adults or those with cardiac problems, kidney problems, pulmonary problems, or liver problems are at greater risk. The presence of crackles in the lungs may be indicative of pulmonary edema, which can occur very quickly and lead to death in patients with fluid overload.)
The nurse associates which assessment finding in the diabetic patient with decreasing renal function? Ketone bodies in the urine during acidosis Glucose in the urine during hyperglycemia Protein in the urine during a random urinalysis White blood cells in the urine during a random urinalysis
Protein in the urine during a random urinalysis (Urine should not contain protein. Proteinuria in a diabetic heralds the beginning of renal insufficiency or diabetic nephropathy with subsequent progression to end stage renal disease. Chronic elevated blood glucose levels can cause renal hypertension and excess kidney perfusion with leakage from the renal vasculature. This leaking allows protein to be filtered into the urine.)
A nurse is caring for a mother and neonate. What is the priority nursing action to prevent heat loss in the neonate immediately after birth? Bottle feeding immediately after birth Dressing the newborn in a shirt and gown immediately Bathing the newborn in warm water as soon as possible Putting the naked newborn on the mother's skin and covering the infant with a blanket
Putting the naked newborn on the mother's skin and covering the infant with a blanket (Skin-to-skin contact between mother and infant is most effective in maintaining the infant's body temperature; heat is transferred by way of conduction. A radiant warmer is effective if the mother or newborn is unable to engage in immediate skin-to-skin contact. Dressing the newborn in a shirt and gown immediately is not effective; also, a blanket and radiant warmer are necessary if skin-to-skin contact with the mother is not possible. Bathing the infant should be delayed until the newborn's body temperature has been stabilized.)
A client with ascites has a paracentesis, and 1500 mL of fluid is removed. For which immediate response is it most important for the nurse to monitor? Rapid, thready pulse Decreased peristalsis Respiratory congestion Increase in temperature
Rapid, thready pulse (Fluid shifts from the intravascular compartment into the abdominal cavity, causing hypovolemia. A rapid, thready pulse, which is indicative of shock, is a compensatory response to this shift. Decreased peristalsis is not likely to occur in the immediate period. After a paracentesis, intravascular fluid shifts into the abdominal cavity, not into the lungs. Increase in temperature is not the priority; body temperature usually is not affected immediately; an infection will take several days.)
A client with type 1 diabetes is admitted to the hospital for major surgery. Before surgery, the client's insulin requirements are elevated but well controlled. What insulin requirements will the nurse anticipate for this client postoperatively? Decrease Fluctuate Increase sharply Remain elevated
Remain elevated (Emotional and physical stress may cause insulin requirements to remain elevated in the postoperative period. Insulin requirements will remain elevated rather than decrease. Fluctuating insulin requirements usually are associated with noncompliance, not surgery. A sharp increase in the client's insulin requirements may indicate sepsis, but this is not expected.)
The nurse identifies which priority nursing invention for a patient with hyperthermia? Initiating seizure precautions Limiting oral intake Providing a blanket Removing excess clothing
Removing excess clothing (The priority nursing intervention would be removal of excess clothing. Seizures may occur because of a high body temperature, so decreasing heat absorption through clothing is the highest priority. Oral intake, especially of fluids, should not be limited for a patient with hyperthermia, because of the dangers of dehydration. Blanketing, like clothing, should be removed.)
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action? Covering the infant with a bath blanket Sponging the infant with tepid alcohol Removing excess clothing from the infant Reassessing the infant's temperature in several hours
Removing excess clothing from the infant (After the initial safety measures and notification of the practitioner have been addressed, excess clothing, which prevents heat loss, should be removed. Covering the infant will increase the temperature because heat loss will be reduced. Alcohol should never be used for infants or children; it causes severe chilling, which can lead to increased metabolic activity and a higher temperature. This high fever requires more frequent readings, usually at least every hour.)
The nurse recommends the pen-injector insulin delivery system for the client with which clinical presentation? Confusion and reliance on another person for insulin injections Requirements for intensive therapy with small, frequent insulin doses Visual impairment affecting the ability to draw up insulin accurately Frequent episodes of hypoglycemia
Requirements for intensive therapy with small, frequent insulin doses (The pen injector allows greater accuracy with small doses of less than 5 units. It is not recommended for those with cognitive or visual impairments or those who suffer frequent hypoglycemic episodes.)
During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. Which action should the nurse take? Rewarm gradually Notify the practitioner Assess for hyperglycemia Record skin temperature hourly
Rewarm gradually (Gradually rewarming an infant experiencing cold stress is essential to avoid compromising the infant's cardiopulmonary status. It is not necessary to notify the practitioner initially. It is the nurse's responsibility to rewarm the infant. An infant experiencing cold stress will become hypoglycemic because glycogen and glucose are metabolized to maintain the core temperature. Skin temperature should be taken at least every 15 minutes until stable.)
A patient injured in an earthquake today when a wall fell on his legs received 9 units of blood an hour ago because he was hemorrhaging. Which laboratory value should the nurse check first when the report returns? Serum sodium Serum potassium Serum total calcium Serum magnesium
Serum potassium (The patient has two major risk factors for hyperkalemia: massive sudden cell death from a crushing injury (potassium shift from cells into the extracellular fluid) and massive blood transfusion (rapid potassium intake). Although massive blood transfusion may cause calcium and magnesium ions to bind to citrate in the blood, thereby decreasing the physiological availability of those ions, it does not decrease the total calcium or magnesium laboratory measurements. Clinically significant changes in serum sodium are the least likely in this patient.)
Before a client has a cardiac catheterization, an electrocardiogram (ECG) is performed, and hypokalemia is suspected. The nurse expects that the diagnosis will be confirmed by which diagnostic test? Complete blood count Serum potassium level X-ray film of long bones Blood cultures times three
Serum potassium level (Hypokalemia is suspected when the T wave on an ECG tracing is depressed or flattened; a serum potassium level less than 3.5 mEq/L (3.5 mmol/L) indicates hypokalemia. Complete blood count, x-ray film of long bones, and blood cultures times three will have no significance in the diagnosis of a potassium deficit.)
A diabetic patient is receiving intravenous insulin. Which laboratory results should the nurse anticipate as a potential problem? Serum chloride level of 90 mmol/L Serum calcium level of 8 mg/dL Serum sodium level of 132 mmol/L Serum potassium level of 2.5 mmol/L
Serum potassium level of 2.5 mmol/L (Insulin activates the sodium-potassium adenosine triphosphatase (ATPase) pump, which increases the movement of potassium from the extracellular fluid into the intracellular fluid, resulting in hypokalemia. The chloride, calcium, and sodium levels are in normal parameters.)
A client is experiencing persistent vomiting, and serum electrolytes have been prescribed. The nurse should monitor which laboratory results? Sodium and chloride levels Bicarbonate and sulfate levels Magnesium and protein levels Calcium and phosphate levels
Sodium and chloride levels (Sodium, which helps regulate the extracellular fluid volume, is lost with vomiting. Chloride, which balances cations in the extracellular compartment, also is lost with vomiting. Because sodium and chloride are parallel electrolytes, hyponatremia will accompany hypochloremia. Bicarbonate and sulfate levels, magnesium and protein levels, and calcium and phosphate levels do not provide significant information in relation to the effects of vomiting.)
A homeless person is brought to the emergency department after prolonged exposure to cold weather. The nurse would assess the patient for what manifestations of hypothermia? Stupor Erythema Increased anxiety Rapid respirations
Stupor (Stupor may occur with hypothermia because of slowed cerebral metabolic processes. Pallor, not erythema, would be present as a result of peripheral vasoconstriction. Drowsiness occurs; the patient would be unable to focus on anxiety-producing aspects of the situation. Respirations would be decreased.)
Which clinical manifestation of decreased renal function in the diabetic clinic should the nurse anticipate as a potential problem? Elevated specific gravity Ketone bodies in the urine Glucose in the urine Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg
Sustained increase in blood pressure from 130/82 mm Hg to 150/110 mm Hg (Hypertension is both a cause and a result of renal dysfunction in the diabetic client. Although ketones and glucose in the urine are findings in diabetes mellitus, they are not specific for renal function. Specific gravity is elevated with dehydration.)
A nurse is teaching a client with type 1 diabetes about assessing for signs and symptoms of hypoglycemia as a result of excessive insulin. What response should the nurse instruct the client to monitor in addition to nervousness and hunger? Thirst Nausea Anorexia Sweating
Sweating (When serum glucose decreases, the sympathetic nervous system is stimulated, resulting in a surge of epinephrine and norepinephrine; this response causes sweating, tremors, tachycardia, palpitations, nervousness, and hunger. Increased thirst (polydipsia) occurs in response to the osmotic diuresis associated with hyperglycemia. The ketosis and acidosis of diabetic ketoacidosis lead to gastrointestinal problems such as nausea, anorexia, vomiting, and abdominal cramping.)
A client who is taking an oral hypoglycemic daily for type 2 diabetes develops the flu and is concerned about the need for special care. What should the nurse instruct the client to do? Skip the oral hypoglycemic pill, drink plenty of fluids, and stay in bed. Avoid food, drink clear liquids, take a daily temperature, and stay in bed. Eat as much as possible, increase fluid intake, and call the office again the next day. Take the oral hypoglycemic pill, drink warm fluids, and perform a serum glucose test before meals and at bedtime
Take the oral hypoglycemic pill, drink warm fluids, and perform a serum glucose test before meals and at bedtime. (Physiological stress increases gluconeogenesis, requiring continued pharmacological therapy despite an inability to eat; fluids prevent dehydration, and monitoring serum glucose levels permits early intervention if necessary. Skipping the oral hypoglycemic can precipitate hyperglycemia; serum glucose levels must be monitored. Food intake should be attempted to prevent acidosis; oral hypoglycemics should be taken, and serum glucose levels should be monitored. Telling the client to eat as much as possible, increase fluid intake, and call the office again the next day are incomplete instructions; oral hypoglycemics should be taken, and serum glucose levels should be monitored. Eating as much as possible can precipitate hyperglycemia.)
A client is admitted with severe burns. The nurse is caring for the client 36 hours after the client's admission and identifies the client's potassium level of 6.0 mEq/L (6.0 mmol/L). Which drink will the nurse recommend be included in the client's diet? Milk Tea Orange juice Tomato juice
Tea (The client is hyperkalemic, and potassium intake should be limited; tea is very low in potassium. Milk, orange juice, and tomato juice are all high-potassium foods and should be avoided.)
The patient has recent bilateral, above-the-knee amputations and has developed C. difficile diarrhea. What assessments should the nurse use to detect ECV deficit in this patient? (Select all that apply.) Test for skin tenting. Measure rate and character of pulse. Measure postural blood pressure and heart rate. Check Trousseau's sign. Observe for flatness of neck veins when upright. Observe for flatness of neck veins when supine.
Test for skin tenting. Measure rate and character of pulse. Observe for flatness of neck veins when supine. (ECV deficit is characterized by skin tenting; rapid, thready pulse; and flat neck veins when supine, which can be assessed in this patient. Although ECV deficit also causes postural blood pressure drop with tachycardia, this assessment is not appropriate for a patient with recent bilateral, above-the-knee amputations. Trousseau's sign is a test for increased neuromuscular excitability, which is not characteristic of ECV deficit. Flat neck veins when upright is a normal finding.)
Which clinical manifestation indicates to the nurse a patient's hyperosmolar nonketotic syndrome (HNKS) therapy needs to be adjusted? Ketone bodies in the urine have been absent for 3 hours. Blood osmolarity has decreased from 350 to 330 mOsm. Serum potassium level has increased from 2.8 to 3.2 mEq/L. The Glasgow Coma Scale is unchanged from 3 hours ago.
The Glasgow Coma Scale is unchanged from 3 hours ago.(Slow but steady improvement in central nervous system functioning should be seen with effective therapy for HNKS. An unchanged level of consciousness may indicate inadequate rates of fluid replacement. Ketone bodies, blood osmolarity, and serum potassium levels are consistent with improvement.)
Which of the following would be included in the assessment of a patient with diabetes mellitus who is experiencing a hypoglycemic reaction? (Select all that apply.) Tremors Nervousness Extreme thirst Flushed skin Profuse perspiration Constricted pupils
Tremors Nervousness Profuse perspiration (When hypoglycemia occurs, blood glucose levels fall, resulting in sympathetic nervous system responses such as tremors, nervousness, and profuse perspiration. Dilated pupils would also occur, not constricted pupils. Extreme thirst, flushed skin, and constricted pupils are consistent with hyperglycemia.)
At change-of-shift report, the nurse learns the medical diagnoses for four patients. Which patient should the nurse assess most carefully for development of hyponatremia? Vomiting all day and not replacing any fluid Tumor that secretes excessive antidiuretic hormone (ADH) Tumor that secretes excessive aldosterone Tumor that destroyed the posterior pituitary gland
Tumor that secretes excessive antidiuretic hormone (ADH) (ADH causes renal reabsorption of water, which dilutes the body fluids. Excessive ADH thus causes hyponatremia. Excessive aldosterone causes ECV excess rather than hyponatremia. The posterior pituitary gland releases ADH; lack of ADH causes hypernatremia. Vomiting without fluid replacement causes ECV deficit and hypernatremia.)
The nurse is assessing a patient before hanging an IV solution of 0.9% NaCl with KCl in it. Which assessment finding should cause the nurse to hold the IV solution and contact the physician? Weight gain of 2 pounds since last week Dry mucous membranes and skin tenting Urine output 8 mL/hr Blood pressure 98/58
Urine output 8 mL/hr (Administering IV potassium to a patient who has oliguria is not safe, because potassium intake faster than potassium output can cause hyperkalemia with dangerous cardiac dysrhythmias. Dry mucous membranes, skin tenting, and blood pressure 98/58 are consistent with the need for IV 0.9% NaCl. Weight gain of 2 pounds in a week does not necessarily indicate fluid overload, because it can be from increased nutritional intake. Only an overnight weight gain indicates a fluid gain.)
The home health nurse has an acute immunodeficiency syndrome (AIDS) patient who has chronic diarrhea. Which assessments should the nurse use to detect the fluid and electrolyte imbalances for which the patient has high risk? (Select all that apply.) Bilateral ankle edema Weaker leg muscles than usual Postural blood pressure and heart rate Positive Trousseau's sign Flat neck veins when upright Decreased patellar reflexes
Weaker leg muscles than usual Postural blood pressure and heart rate Positive Trousseau's sign (Chronic diarrhea has high risk of causing ECV deficit, hypokalemia, hypocalcemia, and hypomagnesemia because it increases fecal excretion of sodium-containing fluid, potassium, calcium, and magnesium. Appropriate assessments include postural blood pressure and heart rate for ECV deficit; weaker leg muscles than usual for hypokalemia; and positive Trousseau's sign for hypocalcemia and hypomagnesemia. Bilateral ankle edema is a sign of ECV excess, which is not likely with chronic diarrhea. Flat neck veins when upright is a normal finding. Decreased patellar reflexes is associated with hypermagnesemia, which is not likely with chronic diarrhea.)
which of the following are considered risk factors for impaired glucose regulation? select all that apply a. african american decent b. elevated vitamin D levels c. high fiber diet d. age greater than 70 e. thyroid disorders
a. african american decent d. age greater than 70 e. thyroid disorders
a gardener has been working outside all day in 100F (37.7C) temperature. what hormone will the client's body release to help the client retain water? a. antidiuretic hormone b. cortisol c. insulin d. renin
a. antidiuretic hormone
which of the following are considered long term care consequences of hyperglycemia? select all that apply a. chronic kidney disease b. hypotension c. neuropathy d. polyphage e. retinopathy
a. chronic kidney disease c. neuropathy e. retinopathy
a 36 year old is newly diagnosed with type 2 diabetes. which of the following treatments do you expect the client to be started on initially? a. diet and exercise regime b. none, monitoring at this time is sufficient c. an oral hypoglycemic medication d. regular insulin subcutaneous
a. diet and exercise regime
which client would be least likely to experience a fluid and electrolyte imbalance? a. a 6 month old with a common cold b. a 23 year old with an upper extremity bone fracture c. a 48 year old with a history of renal disease d. an 86 year old living in a long term care facility
b. a 23 year old with an upper extremity bone fracture
a client is admitted to the hospital with an acute ulcerative colitis flare up. the nurse is concerned about the clients magnesium level of 0.8 mEg/l. which signs and symptoms could the nurse expect to see? select all that apply a. vertigo b. confusion c. hypoactive deep tendon reflexes d. twitching e. seizures f. bradycardia
b. confusion d. twitching e. seizures
a client has been fasting for 8 hours. the clients blood glucose level is 112. which of the following terms best describes the clients state? a. euglycemia b. hyperglycemia c. hypoglycemia d. normoglycemia
b. hyperglycemia
which signs and symptoms are associated with too little volume ( a fluid deficit) select all that apply a. bounding pulse b. oliguria c. skin tenting d. dyspnea e. postural hypotension
b. oliguria c. skin tenting e. postural hypotension
an older adult male with a history of multiple medical problems is recovering from right hip surgery. loperamide has been prescribed. which would indicate to the nurse that the medication was effective? a. increased frequency of bowel movements b. client experiences no post operative constipation c. formed bowel movements d. improved post operative mobility
c. formed bowel movements
which body system is most significantly affected by a lack of glucose availability? a. cardiovascular system b. gastrointestinal system c. integumentary system d. neurological system
d. neurological system
which statement best describes the concept of fluid and electrolyte balance? a. the movement of fluids and electrolytes in the body to maintain homeostasis b. the process by which electrolytes are circulated within the human body to maintain homeostasis c. the process by which the human body excretes fluids and electrolytes d. the process of regulating the extracellular fluid volume, body fluid osmolarity and plasma concentrations of electrolytes
d. the process of regulating the extracellular fluid volume, body fluid osmolarity, and plasma concentrations of electrolytes
The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is: large for gestational age. low birth weight. born at term. well nourished.
low birth weight. (Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk.)
The nurse planning care for a patient with hypothermia would consider knowledge of similar exemplars including: heat exhaustion. heat stroke. infection. prematurity.
prematurity. (Prematurity, frost bite, environmental exposure, and brain injury are considered exemplars of hypothermia. Heat exhaustion is an exemplar of hyperthermia. Heat stroke is an exemplar of hyperthermia. Infection is an exemplar of hyperthermia.)
The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n): oral thermometer. rectal thermometer. temporal thermometer scan. tympanic membrane sensor.
rectal thermometer. (The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment.)
The nurse admitting a patient to the emergency department on a very hot summer day would suspect hyperthermia when the patient demonstrates: decreased respirations. low pulse rate. red, sweaty skin. slow capillary refill.
red, sweaty skin. (With hyperthermia, vasodilatation occurs causing the skin to appear flushed and warm or hot to touch. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. With hypothermia there is slow capillary refill.)
The priority nursing intervention for a patient suspected to be hypothermic would be to: assess vital signs. hydrate with intravenous (IV) fluids. provide a warm blanket. remove wet clothes.
remove wet clothes. (The first thing to do with a patient suspected to be hypothermic is to remove wet clothes, because heat loss is five times greater when clothing is wet. Assessing vital signs is important, but the wet clothes should be removed first. Hydration is very important with hyperthermia and the associated danger of dehydration, but there is not a similar risk with hypothermia. A warm blanket over wet clothes would not be an effective warming strategy.)
Strategies to include in a community program for senior citizens related to dealing with cold winter temperatures would include: avoiding hot beverages. shopping at an indoor mall. using a fan at low speed. walking slowly in the park.
shopping at an indoor mall. (Shopping indoors where there is protection from the elements and temperature control is one strategy to avoid cold temperatures. Hot beverages can help an individual deal with cold weather. Avoiding breezes and air currents is recommended to conserve body temperature. Physical activity can increase body temperature, and if the senior is going to walk in the park, weather-appropriate (warm) clothing and a usual or brisk pace, not a slow pace, would be recommended.)
The nurse admitting a patient to the emergency room on a cold winter night would suspect hypothermia when the patient demonstrates: increased respirations. rapid pulse rate. red, sweaty skin. slow capillary refill.
slow capillary refill. (With hypothermia, there is slow capillary refill. There is an increased respiration rate with hyperthermia. The heart rate increases with hyperthermia. The skin is usually pale or cyanotic with hypothermia.)
A volunteer at the senior center asks the visiting nurse why the senior citizens always seem to be complaining about temperatures. The nurse's best response is that older people have a diminished ability to regulate body temperature because of: active sweat glands. increased circulation. peripheral vasoconstriction. slower metabolic rates.
slower metabolic rates. (Slower metabolic rates are one factor that reduces the ability of older adults to regulate temperature and be comfortable when there are any temperature changes. As the body ages, the sweat glands decrease in number and efficiency. Older adults have reduced circulation. The body conserves heat through peripheral vasoconstriction, and older adults have a decreased vasoconstrictive response, which impacts ability to respond to temperature changes.)
A patient has acute gastroenteritis with watery diarrhea. Which statement by this patient would indicate that the nurse's teaching has been effective? "I should drink a lot of tap water today." "I need to take more calcium tablets today." "I should avoid fruits with potassium in them." "I need to drink liquids with some sodium in them."
"I need to drink liquids with some sodium in them." (Sodium-containing fluids are removed from the body by acute diarrhea and must be replaced to prevent an extracellular fluid volume (ECV) deficit. Drinking tap water will not prevent ECV deficit from diarrhea, because tap water does not contain enough sodium to hold the water in the extracellular compartment. Taking calcium tablets is an incorrect answer because hypocalcemia is characteristic of chronic diarrhea rather than acute diarrhea. Restricting fruits is an incorrect answer because diarrhea increases the potassium output and the potassium intake should be increased to balance it.)
A nurse teaches a client with type 2 diabetes how to provide self-care to prevent infections of the feet. Which statement made by the client shows that teaching was effective? "I should massage my feet and legs with oil or lotion." "I should apply heat intermittently to my feet and legs." "I should eat foods high in protein and carbohydrate kilocalories." "I should control my blood glucose with diet, exercise, and medication."
"I should control my blood glucose with diet, exercise, and medication." (Controlling the diabetes decreases the risk of infection; this is the best prevention. Oil or lotion that is not completely absorbed may provide a warm, moist environment for bacterial growth. Coexisting neuropathy may result in injury from heat application. Protein, carbohydrates, and fats must be in an appropriate balance; high carbohydrate intake can provide too many calories.)
The nurse is teaching a client about the prescribed diet after a Whipple procedure for cancer of the pancreas. Which statement should the nurse include in the dietary teaching? "There are no dietary restrictions because the tumor has been removed." "Your diet should be low in calories to prevent taxing your diseased pancreas." "Meals should be restricted in protein because of your compromised liver function." "Low-fat meals should be eaten to prevent interference with your fat digestion mechanism."
"Low-fat meals should be eaten to prevent interference with your fat digestion mechanism." (Whipple procedure leads to malabsorption because of impaired delivery of bile to the intestine and interruption of glucose metabolism; interference with fat digestion occurs. Clients require small, frequent low-fat, high-protein, moderate-carbohydrate meals and supplemental feedings. The response "There are no dietary restrictions because the tumor has been removed" is false reassurance. High-calorie meals are needed to provide energy and to promote the use of protein for tissue repair. High protein is required for tissue building; there is no problem with the liver in clients with cancer of the pancreas unless metastasis occurs by direct extension.)
A diabetic patient has proliferative retinopathy, nephropathy, and peripheral neuropathy. What should the nurse teach this patient about exercise? "Jogging for 20 minutes 5 to 7 days a week would most efficiently help you to lose weight." "One hour of vigorous exercise daily is needed to prevent progression of disease." "Avoid all forms of exercise because of your diabetic complications." "Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you."
"Swimming or water aerobics 30 minutes each day would be the safest exercise routine for you." (Exercise is not contraindicated for this client, but modifications are necessary to prevent further injury. Swimming or water aerobics provides support for the joints and muscles while increasing the uptake of glucose and promoting cardiovascular health. Jogging, vigorous exercise, or no exercise would increase the pathologies of this patient.)
When a diabetic patient asks about maintaining adequate blood glucose levels, which of the following statements by the nurse relates most directly to the necessity of maintaining blood glucose levels no lower than about 74 mg/dl? "Glucose is the only type of fuel used by body cells to produce the energy needed for physiologic activity." "The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel." "Without a minimum level of glucose circulating in the blood, erythrocytes cannot produce ATP." "The presence of glucose in the blood counteracts the formation of lactic acid and prevents acidosis."
"The central nervous system cannot store glucose and needs a continuous supply of glucose for fuel." (The brain cannot synthesize or store significant amounts of glucose; thus a continuous supply from the body's circulation is needed to meet the fuel demands of the central nervous system.)
A client with type 1 diabetes asks what causes the several brown spots on the skin. What would be the best response by the nurse? "The brown spots reflect the accumulation of blood fats in the skin; they should disappear." "Those spots indicate a high glucose content in the skin that may get infected if left untreated." "They are the result of diseased small vessels in the shins and may spread if not treated soon." "Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot."
"Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot." ("Those brown spots result from small blood vessel damage; the blood contains iron, which leaves a brown spot" is an accurate explanation for the client's concern; brown spots are caused by the deposit of hemosiderin in the tissue. Brown spots reflecting the accumulation of blood fats in the skin and disappearing is the definition of a xanthoma. A high glucose content in the skin that has become infected is not the cause of brown spots on the skin; increased glucose in the skin is not observable by inspection. Brown spots result from the deposition of hemosiderin. Blood vessels may become diseased with diabetes, but this does not cause brown spots.)
What is the nurse's best response about developing diabetes to the patient whose father has type 1 diabetes mellitus? "You have a greater susceptibility for development of the disease because of your family history." "Your risk is the same as the general population, because there is no genetic risk for development of type 1 diabetes." "Type 1 diabetes is inherited in an autosomal dominant pattern. Therefore the risk for becoming diabetic is 50%." "Because you are a woman and your father is the parent with diabetes, your risk is not increased for eventual development of the disease. However, your brothers will become diabetic."
"You have a greater susceptibility for development of the disease because of your family history." (Even though type 1 diabetes does not follow a specific genetic pattern of inheritance, those with one parent with type 1 diabetes are at an increased risk for development of the disease.)
An older adult with chills arrived to hospital. The nurse assesses the client's vital signs and determined the client has a fever. What would be the client's rectal temperature? 36.0ºC 36.8ºC 37.2ºC 38.5ºC
38.5ºC (In older adults the normal temperature range is 36° to 36.8°C orally and 36.6° to 37.2°C rectally. In febrile conditions, the rectal temperature would be more than 37.5°C. A rectal temperature of 38.5°C would indicate a fever.)
After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.9° C). Which priority concern related to elevated temperatures does a nurse consider when notifying the healthcare provider about the client's temperature? A fever may lead to diaphoresis. A fever increases the cardiac output. An increased temperature indicates cerebral edema. An increased temperature may be a sign of hemorrhage.
A fever increases the cardiac output. (Temperatures of 102° F (38.9° C) or greater lead to an increased metabolism and cardiac workload. Although diaphoresis is related to an elevated temperature, it is not the reason for notifying the healthcare provider. An elevated temperature is not an early sign of cerebral edema. Open heart surgery is not associated with cerebral edema. Fever is unrelated to hemorrhage; in hemorrhage with shock, the temperature decreases.)
A child is about to be admitted to the pediatric intensive care unit (PICU) after surgery for removal of a tumor in the hypothalamic region of the brain. The nurse manager should intervene immediately when observing the child's nurse perform which action? Places a hypothermia blanket at the bedside Adjusts the bed to the Trendelenburg position Obtains electronic equipment for monitoring the vital signs Secures a pump to administer the ordered intravenous fluids
Adjusts the bed to the Trendelenburg position (It is not safe to put the bed in the Trendelenburg position, because raising the foot increases blood flow to the brain, thereby increasing intracranial pressure. Temperature elevations may occur after a craniotomy because of stimulation of the hypothalamus. A hypothermic blanket should be ready if the temperature becomes precipitously elevated. Monitoring vital signs is a critical component of postoperative care. Intravenous infusions must be regulated precisely to minimize the possibility of cerebral edema.)
Which priority intervention will the nurse initiate for the patient having Kussmaul's respirations due to diabetic ketoacidosis? Administration of oxygen by nasal cannula at 15 L/min Intravenous infusion of 10% glucose Implementation of seizure precautions Administration of intravenous insulin
Administration of intravenous insulin (The Kussmaul's respirations pattern is the body's attempt to reduce the acids produced by utilization of fat for fuel. Administration of insulin will reduce this respiration pattern by assisting glucose transport back into cells to be used for fuel instead of fat. Nasal cannula oxygen is given at 1 to 6 L per minute; intravenous glucose administration will not have the desired effect of treatment; and although seizure precautions may be implemented, they will not have any effect on glucose transport into cells.)
The nurse teaches which action to the diabetic client who self-injects insulin to prevent local irritation at the injection site? Be sure to aspirate prior to injecting insulin. Massage the site after injecting insulin. Use a 1-inch needle for the injection. Allow the insulin to warm to room temperature before injecting it.
Allow the insulin to warm to room temperature before injecting it. (Cold insulin from the refrigerator is the most common cause of irritation. Aspiration of insulin is not recommended; massaging the site can cause irritation; and a 1-inch needle is the improper size for insulin injections.)
What is the priority nursing intervention for a client with stroke who is transitioned from ED to other settings? Monitoring vital signs Reassuring the client and family Assessing the level of consciousness Monitoring specific patient manifestations of stroke
Assessing the level of consciousness (Assessing the level of consciousness is the priority nursing action in the client with stroke and who is transitioned from ED to other settings. Monitoring the vital signs, reassuring the client and family, and monitoring specific patient manifestations of stroke are ongoing nursing interventions.)
The nurse is assessing a client with hemorrhagic stroke due to a motor bike accident. Which condition of the client requires immediate attention? Glasgow Coma score of 10 Body temperature of 81.2°F Oxygen saturation of 90 percent Presence of carotid pulse with blood pressure of 80 mm Hg
Body temperature of 81.2°F (Severe hypothermia such as body temperature of 81.2° F must be immediately corrected by infusing warm fluids and blood. This helps to prevent hypothermia-related complications. A Glasgow Coma score of 10 needs medium priority since it does indicate immediate danger to the client. Oxygen saturation of 90 percent indicates a manageable status. Presence of carotid pulse with blood pressure of 80 mm Hg is acceptable.)
The nurse is assessing the core body temperature of four clients. Which client requires priority critical care? Client with body temperature of 27°C. Client with body temperature of 29°C. Client with body temperature of 30°C. Client with body temperature of 32°C.
Client with body temperature of 27°C. (Severe hypothermia, or a core body temperature below 82.4° F (28° C), can cause cardiac arrest. Therefore the client with a core body temperature of 27°C should be treated first to ensure safety. Clients with moderate hypothermia (82.4° to 90° F [28° to 32° C]) are at lesser risk for cardiac arrest than clients with severe hypothermia. Therefore clients with core body temperatures of 30°C, 32°C, and 29°C can be treated after treating the client with a core body temperature of 27°C.)
A nurse assesses a client's intravenous site. What clinical finding, unique to infiltration, leads the nurse to conclude that the intravenous (IV) site has infiltrated, rather than become inflamed? Pain Coolness Localized swelling Cessation in flow of solution
Coolness (When an IV infiltrates, the IV solution entering the interstitial space is at room temperature (approximately 75° F [23.9° C]), whereas body temperature is approximately 98.6° F (37° C); therefore, the client's skin will feel cool to the touch at the site of an IV infiltration. The site of an inflammation will feel warm to the touch because of vasodilation and hyperemia. Pain may occur with both an inflammation and an infiltration. The pain of an inflammation is related to the pressure of edema on nerve endings. The pain of an infiltration is related to the IV solution in the interstitial compartment pressing on nerve endings. An increase in interstitial fluid occurs with both an inflammation and an infiltration. With an inflammation there is increased vascular permeability at the site; fluid, proteins, and leukocytes then move from the intravascular compartment into the interstitial compartment. With an infiltration the IV solution enters the interstitial compartment rather than the intravascular compartment. A cessation in flow of solution occurs with both an inflammation and an infiltration. An inflammation in the vein at the insertion site may close the lumen of the vessel, interfering with the flow of solution. An infiltration will cause excess fluid in the interstitial compartment to the extent that it will not accommodate more solution, interfering with the flow of the solution.)
A patient with hypothermia is brought to the emergency department. The nurse should explain which most likely treatment to the family members? Core rewarming with warm fluids Ambulation to increase metabolism Frequent oral temperature assessment Gastric tube feedings to increase fluids
Core rewarming with warm fluids (Core rewarming with heated oxygen and administration of warmed oral or intravenous fluids is the preferred method of treatment. The patient would be too weak to ambulate. Oral temperatures are not the most accurate assessment of core temperature because of environmental influences. Warmed oral feedings are advised; gastric gavage is unnecessary.)
