Exam 1 Pretest
A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to: low platelet count. low sodium level. decreased prothrombin time. low hemoglobin.
low platelet count. Prolonged prothrombin time (PT) and low platelet count place the client at high risk for hemorrhage. The client may receive intravenous (IV) administration of vitamin K or infusions of platelets before liver biopsy to reduce the risk of bleeding.
A 33-year-old male patient with a history of IV heroin and cocaine use has been admitted to the medical unit for the treatment of endocarditis. The nurse should recognize that this patient is also likely to test positive for which of the following hepatitis viruses? Hepatitis A Hepatitis B Hepatitis C Hepatitis D
Hepatitis C explanation: Transmission of hepatitis C occurs primarily through injection of drugs and through transfusion of blood products prior to 1992. Hepatitis A, B, and D are less likely to result from IV drug use.
A patient is prescribed Glucophage, an oral antidiabetic agent classified as a biguanide. The nurse knows that a primary action of this drug is its ability to: Stimulate the beta cells of the pancreas to secrete insulin. Decrease the body's sensitivity to insulin. Inhibit the production of glucose by the liver. Increase the absorption of carbohydrates in the intestines.
Inhibit the production of glucose by the liver.
After teaching a class about agents commonly associated with the development of malignant hyperthermia, the instructor determines that additional teaching is needed when the students identify which drug as a possible cause? Halothane Succinylcholine Epinephrine Morphine
Morphine explanation: Morphine is not associated with malignant hyperthermia. Agents such as halothane, succinylcholine, and epinephrine can induce malignant hyperthermia.
Which findings would be indicative of a nursing diagnosis of decreased cardiac output? urinary output > 60 ml; BP 90/60; tachypnea bradycardia; urinary output < 30 ml; confusion tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 confusion; tachypnea; hemoglobin 14.2 gm/dL
tachycardia; hemoglobin 10.9 gm/dL; BP 88/56 explanation: Clinical manifestations of decreased cardiac output include tachycardia, tachypnea, urinary output < 30 ml/hr, decreased hemoglobin and hematocrit, and acute confusion.
Which of the following insulins are used for basal dosage? Glargine (Lantus) NPH (Humulin N) Lispro (Humalog) Aspart (Novolog)
Glargine (Lantus) explanation: Lantus is used for basal dosage. NPH is an intermediate acting insulin, usually taken after food. Humalog and Novolog are rapid-acting insulins.
A diabetes nurse is assessing a client's knowledge of self-care skills. What would be the most appropriate way for the educator to assess the client's knowledge of nutritional therapy in diabetes? Have the client describe an optimally healthy meal. Ask the client to keep a food diary and review it with the nurse. Have the client's family describe what he typically eats. Ask the client to describe a typical day's food intake.
Ask the client to keep a food diary and review it with the nurse. explanation: Reviewing the client's actual food intake is the most accurate method of gauging the client's diet.
A nurse is caring for a client who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this client's plan of care? Measurement of abdominal girth and body weight Assessment for variceal bleeding Assessment for signs and symptoms of jaundice Monitoring of results of liver function testing
Assessment for variceal bleeding explanation: Esophageal varices are a major cause of mortality in clients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed.
Once digested, what percentage of carbohydrates is converted to glucose? 70 80 90 100
100% explanation: Once digested, 100% of carbohydrates are converted to glucose. However, approximately 50% of protein foods are also converted to glucose, but this has minimal effect on blood glucose concentration.
While talking with a client who has been diagnosed with a terminal illness, the client asks, " Am I dying?" Which response from the nurse would be appropriate? Select all that apply. "I know just how you must feel." "This must be very difficult for you." "Tell me more about what's on your mind." "You still have time for a good life." "Let's focus on what your doctor has planned."
"This must be very difficult for you." "Tell me more about what's on your mind." explanation: The nurse needs to listen effectively and empathetically, acknowledging the client's fears and concerns. Statements such as "This must be very difficult for you" and "Tell me more about what's on your mind" address the client's concerns and help to focus the discussion on the client. Telling the client that the nurse knows how the client feels ignores the client's concerns. Saying that there is still time for a good life or telling the client to focus on what the doctor has planned ignores the client's feelings and blocks communication.
Which of the following is a clinical manifestation of fluid volume excess (FVE)? Select all that apply. Distended neck veins Crackles in the lung fields Shortness of breath Decreased blood pressure Bradycardia
Distended neck veins Crackles in the lung fields Shortness of breath explanation: Clinical manifestations of FVE (hypervolemia) include distended neck veins, crackles in the lung fields, shortness of breath, increased blood pressure, and tachycardia.
The advance nurse practitioner, who is treating a client diagnosed with neuropathic pain, decides to start adjuvant analgesic agent therapy. Which medication is appropriate for the nurse practitioner to prescribe? Tramadol Ketamine Gabapentin Hydromorphone
Gabapentin explanation: The anticonvulsant gabapentin is a first-line analgesic agent for neuropathic pain. Tramadol is designated as a second-line analgesic agent for the treatment of neuropathic pain. Ketamine is used as a third-line analgesic agent for refractory acute pain. Hydromorphone is a first-line opioid not used as an analgesic agent for neuropathic pain.
A nurse has entered the room of a client with cirrhosis and found the client on the floor. The client reports falling when transferring to the commode. The client's vital signs are within reference ranges and the nurse observes no apparent injuries. What is the nurse's most appropriate action? Remove the client's commode and supply a bedpan. Complete an incident report and submit it to the unit supervisor. Have the client assessed by the primary provider due to the risk of internal bleeding. Perform a focused abdominal assessment in order to rule out injury.
Have the client assessed by the primary provider due to the risk of internal bleeding. explanation: A fall would necessitate thorough medical assessment due to the client's risk of bleeding. The nurse's abdominal assessment is an appropriate action, but is not wholly sufficient to rule out internal injury. Medical assessment is a priority over removing the commode or filling out an incident report, even though these actions are appropriate.
A client is admitted with diabetic ketoacidosis (DKA). Which order from the physician should the nurse implement first? Start an infusion of regular insulin at 50 U/hr. Administer sodium bicarbonate 50 mEq IV push. Infuse 0.9% normal saline solution 1 L/hr for 2 hours. Administer regular insulin 30 U IV push.
Infuse 0.9% normal saline solution 1 L/hr for 2 hours. explanation: In addition to treating hyperglycemia, management of DKA is aimed at correcting dehydration, electrolyte loss, and acidosis before correcting the hyperglycemia with insulin. In dehydrated clients, rehydration is important for maintaining tissue perfusion. Initially, 0.9% sodium chloride (normal saline) solution is administered at a rapid rate, usually 0.5 to 1 L/hr for 2 to 3 hours.
What is the priority action when the circulating nurse is completing a second verification of the surgical procedure and surgical site? Ask the surgeon whether the marked surgical site is correct. Obtain the attention of all members of the surgical team. Discuss the surgical procedure and surgical site with the client. Review complications and allergies with the anesthesiologist.
Obtain the attention of all members of the surgical team. explanation: The second verification of the surgical procedure and surgical site should be done at one time and include all members of the surgical team. The marked surgical site is confirmed with all members of the surgical team, not just the surgeon or client. Complications, allergies, and anticipated problems are also discussed among the entire surgical team.
A client has undergone a liver biopsy. Which postprocedure position is appropriate? On the left side Trendelenburg On the right side High Fowler
On the right side explanation: In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on his left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.
Which category of oral antidiabetic agents exerts the primary action by directly stimulating the pancreas to secrete insulin? Thiazolidinediones Biguanides Alpha-glucosidase inhibitors Sulfonylureas
Sulfonylureas explanation: A functioning pancreas is necessary for sulfonylureas to be effective. Thiazolidinediones enhance insulin action at the receptor site without increasing insulin secretion from the beta cells of the pancreas. Biguanides facilitate the action of insulin on peripheral receptor sites. Alpha-glucosidase inhibitors delay the absorption of glucose in the intestinal system, resulting in a lower postprandial blood glucose level.
The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose? Watery diarrhea Vomiting Ringing in the ears Asterixis
Watery diarrhea explanation: The patient receiving lactulose is monitored closely for the development of watery diarrhea stools, because they indicate a medication overdose. Serum ammonia levels are closely monitored as well.
A client with viral hepatitis A is being treated in an acute care facility. Because the client requires enteric precautions, the nurse should: place the client in a private room. wear a mask when handling the client's bedpan. wash her hands after touching the client. wear a gown when providing personal care for the client.
wash her hands after touching the client. explanation: To maintain enteric precautions, the nurse must wash her hands after touching the client or potentially contaminated articles and before caring for another client. A private room is warranted only if the client has poor hygiene — for instance, if the client is unlikely to wash the hands after touching infective material or is likely to share contaminated articles with other clients. For enteric precautions, the nurse need not wear a mask and must wear a gown only if soiling from fecal matter is likely.
A nurse is caring for a client who is terminally ill and is inquiring about physician-assisted suicide. Which statement if made by the nurse would correctly inform the client of this practice? "The health care provider administers an analgesic at a level that renders the client unconscious." "The health care provider provides the means for the clients to take their life." "The health care provider provides the means and the nurse assists the client in ending their life." "The health care provider provides the means for suicide to clients who require palliative care."
"The health care provider provides the means for the clients to take their life." explanation: Physician-assisted suicide is the practice of providing a means by which a client can end their life. Much controversy exists concerning the practice. California, Vermont, Oregon, Washington, and Montana are the only states that permit physician-assisted suicide. Administering analgesics at a level that renders the client unconscious is referred to as passive euthanasia as it is believed to facilitate death by letting "nature take its course." It is different than a provider providing the means for the client to take their own life. The health care provider may provide the means for the client to end their life, but the nurse does not assist the client in the act. Nurse practice prohibit nurses from assisting clients to die. Health care provider-assisted suicide is not considered part of palliative care. Palliative care is an approach that improves the quality of life of those at the end of life. It neither hastens nor postpones death; it provides relief from pain and discomfort, addresses spiritual needs, and provides emotional support to the client and family.
What percentage of potassium excreted daily leaves the body by way of the kidneys?
80% To maintain the potassium balance, the renal system must function, because 80% of the potassium excreted daily leaves the body by way of the kidneys. The other numerical values are incorrect.
A local public health nurse is informed that a cook in a local restaurant has been diagnosed with hepatitis A. What should the nurse advise individuals to obtain who ate at this restaurant and have never received the hepatitis A vaccine? The hepatitis A vaccine Albumin infusion The hepatitis A and B vaccines An immune globulin injection
An immune globulin injection explanation: For people who have not been previously vaccinated, hepatitis A can be prevented by the intramuscular administration of immune globulin during the incubation period, if given within 2 weeks of exposure. Administration of the hepatitis A vaccine will not protect the client exposed to hepatitis A, as protection will take a few weeks to develop after the first dose of the vaccine. The hepatitis B vaccine provides protection against the hepatitis B virus, but plays no role in protection for the client exposed to hepatitis A. Albumin confers no therapeutic benefit.
A client with portal hypertension has been admitted to the medical floor. The nurse should prioritize what assessments? Assessment of blood pressure and assessment for headaches and visual changes Assessments for signs and symptoms of venous thromboembolism Daily weights and abdominal girth measurement Blood glucose monitoring q4h
Daily weights and abdominal girth measurement Obstruction to blood flow through the damaged liver results in increased blood pressure (portal hypertension) throughout the portal venous system. This can result in varices and ascites in the abdominal cavity. Assessments related to ascites are daily weights and abdominal girths. Portal hypertension is not synonymous with cardiovascular hypertension and does not create a risk for unstable blood glucose or VTE.
A client with hypertension has been prescribed hydrochlorothiazide. What nursing action will best reduce the client's risk for electrolyte disturbances? Maintain a low-sodium diet. Encourage the use of over-the-counter calcium supplements. Ensure the client has sufficient potassium intake. Encourage fluid intake.
Ensure the client has sufficient potassium intake. Thiazide diuretics, such as hydrochlorothiazide, cause potassium loss, and it is important to maintain adequate intake during therapy. Hyponatremia is more of a risk than hypernatremia, so a low-sodium diet does not address the risk for electrolyte disturbances. There is no direct need for extra calcium intake, and increased fluid intake does not reduce the client's risk for electrolyte disturbances.
A client presents to the clinic reporting symptoms that suggest diabetes. What criteria would support checking blood levels for the diagnosis of diabetes?
Fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L) Criteria for the diagnosis of diabetes include symptoms of diabetes plus random plasma glucose greater than or equal to 200 mg/dL (11.1 mmol/L), or a fasting plasma glucose greater than or equal to 126 mg/dL (7.0 mmol/L).
The nurse is caring for a client who is being treated on the oncology unit with a diagnosis of lung cancer with bone metastases. The client reports a new onset of weakness with abdominal pain and further assessment suggests that the client likely has a fluid volume deficit. The nurse should recognize that this client may be experiencing which electrolyte imbalance? Hypernatremia Hypomagnesemia Hypophosphatemia Hypercalcemia
Hypercalcemia The most common causes of hypercalcemia are malignancies and hyperparathyroidism. Anorexia, nausea, vomiting, and constipation are common symptoms of hypercalcemia. Dehydration occurs with nausea, vomiting, anorexia, and calcium reabsorption at the proximal renal tubule. Abdominal and bone pain may also be present. Primary manifestations of hypernatremia are neurologic and would not include abdominal pain and dehydration. Tetany is the most characteristic manifestation of hypomagnesemia, and this scenario does not mention tetany. The client's presentation is inconsistent with hypophosphatemia.
When caring for a client who has risk factors for fluid and electrolyte imbalances, which assessment finding is the highest priority for the nurse to follow up? Irregular heart rate Weight loss of 4 lb Mild confusion Blood pressure 96/53 mm Hg
Irregular heart rate Irregular heart rate may indicate a potentially life-threatening cardiac dysrhythmia. Potassium, magnesium, and calcium imbalances may cause dysrhythmias. Weight loss is a good indicator of the amount of fluid lost, confusion may occur with dehydration and hyponatremia, and blood pressure is slightly lower than normal (though not life threatening); in each case, following up on potential cardiac dysrhythmias is a higher priority.
While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the likelihood of liver problems? Select all that apply. Jaundice Petechiae Ecchymoses Cyanosis of the lips Aphthous stomatitis
Jaundice Petechiae Ecchymoses explanation: The skin, mucosa, and sclerae are inspected for jaundice. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. Cyanosis of the lips is indicative of a problem with respiratory or cardiovascular dysfunction. Aphthous stomatitis is a term for mouth ulcers and is a gastrointestinal abnormal finding.
A client newly diagnosed with type 2 diabetes is attending a nutrition class. What general guideline should the nurse teach the clients at this class? Low fat generally indicates low sugar. Protein should constitute 30% to 40% of caloric intake. Most calories should be derived from carbohydrates. Animal fats should be eliminated from the diet.
Most calories should be derived from carbohydrates. explanation: For all levels of caloric intake, 50% to 60% of calories should be derived from carbohydrates, 20% to 30% from fat, and the remaining 10% to 20% from protein. Low fat does not automatically mean low sugar. Dietary animal fat does not need to be eliminated from the diet.
Which of the following factors should the nurse take into consideration when planning meals and selecting the type and dosage of insulin or oral hypoglycemic agent for an elderly patient with diabetes mellitus? Patient's eating and sleeping habits Patient's ability to self-administer insulin Cognitive problems Patient's history
Patient's eating and sleeping habits explanation: The eating and sleeping habits of older adults differ from those of young or middle-aged persons. The nurse should take this into consideration when planning meals and selecting the proper type and dosage of insulin or oral hypoglycemic agent. The nurse should evaluate the patient's ability to self-administer insulin before developing a teaching program. Cognitive problems and patient history may not be taken into consideration when planning meals and selecting the proper type and dosage of insulin or oral hypoglycemic agent.
The nurse recognizes that written informed consent is required for insertion of a(n): Nasogastric tube. Urinary catheter. Peripherally-inserted central catheter. Oral airway.
Peripherally-inserted central catheter. explanation: Nonsurgical invasive procedures, such as insertion of a peripherally-inserted central catheter, that carry more than a slight risk to the client require written informed consent.
A hospice nurse is caring for a young adult client with a terminal diagnosis of leukemia. When updating this client's plan of nursing care, what should the nurse prioritize? Interventions aimed at maximizing quantity of life Providing financial advice to pay for care Providing realistic emotional preparation for death Making suggestions to maximize family social interactions after the client's death
Providing realistic emotional preparation for death Hospice care focuses on quality of life, but, by necessity, it usually includes realistic emotional, social, spiritual, and financial preparation for death. Financial advice and actions aimed at post-death interaction would not be appropriate priorities.
Laboratory studies indicate a client's blood glucose level is 185 mg/dl. Two hours have passed since the client ate breakfast. Which test would yield the most conclusive diagnostic information about the client's glucose use? Fasting blood glucose test 6-hour glucose tolerance test Serum glycosylated hemoglobin (Hb A1c) Urine ketones
Serum glycosylated hemoglobin (Hb A1c) explanation: Hb A1c is the most reliable indicator of glucose use because it reflects blood glucose levels for the prior 3 months. Although a fasting blood glucose test and a 6-hour glucose tolerance test yield information about a client's use of glucose, the results are influenced by such factors as whether the client recently ate breakfast. Presence of ketones in the urine also provides information about glucose use but is limited in its diagnostic significance.
The nurse is caring for a client with a secondary diagnosis of hypermagnesemia. What assessment finding would be most consistent with this diagnosis? Hypertension Kussmaul respirations Increased DTRs Shallow respirations
Shallow respirations If hypermagnesemia is suspected, the nurse monitors the vital signs, noting hypotension and shallow respirations. The nurse also observes for decreased DTRs and changes in the level of consciousness. Kussmaul breathing is a deep and labored breathing pattern associated with severe metabolic acidosis, particularly diabetic ketoacidosis (DKA), but also kidney disease. This type of client is associated with decreased DTRs, not increased DTRs.
The perioperative nurse is constantly assessing the surgical client for signs and symptoms of complications of surgery. Which symptom should first signal to the nurse the possibility that the client is developing malignant hyperthermia? Increased temperature Oliguria Tachycardia Hypotension
Tachycardia explanation: The initial symptoms of malignant hyperthermia are related to cardiovascular and musculoskeletal activity. Tachycardia (heart rate greater than 150 beats per minute) is often the earliest sign. Oliguria, hypotension, and increased temperature are later signs of malignant hyperthermia.
A nurse is assessing the postoperative client on the second postoperative day. What assessment finding requires the nurse to immediately notify the health care provider? The client has an absence of bowel sounds. The client's lungs reveal rales in the bases. The client states a moderate amount of pain at the incisional site. A moderate amount of serous drainage is noted on the operative dressing.
The client has an absence of bowel sounds. explanation: A nursing assessment finding of concern on the second postoperative day is the absence of bowel sounds, which may indicate a paralytic ileus. Other assessment findings may include abdominal pain and distention as fluids, solids, and gas do not move through the intestinal tract. Rales in the bases are a frequent finding postoperatively, especially if general anesthesia was administered. Encourage the client to cough and breathe deep. Pain is a common symptom following a surgical procedure. Serous drainage on the postoperative dressing needs to monitored and brought to the physician's attention when assessing the client.
The postanesthesia care unit nurse is caring for a client who has arrived from the operating room. During the initial assessment, the nurse observes that the client's skin has become blue and dusky. The nurse looks, listens, and feels for breathing, and determines the client is not breathing. Which intervention is the priority? Check the client's oxygen saturation level, and monitor for apnea. Tilt the head back and push forward on the angle of the lower jaw. Assess the arterial pulses, and place the client in the Trendelenburg position. Reintubate the client, and perform a focused assessment.
Tilt the head back and push forward on the angle of the lower jaw. explanation: When a nurse finds a client who is not breathing, the priority intervention is to open the airway and treat a possible hypopharyngeal obstruction. To treat the possible airway obstruction, the nurse tilts the head back and then pushes forward on the angle of the lower jaw or performs the jaw thrust method to open the airway. This is an emergency and requires the basic life support intervention of airway, breathing, and circulation assessment. Arterial pulses should be checked only after airway and breathing have been established. Reintubation and resuscitation would begin after rapidly ruling out a hypopharyngeal obstruction.
A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for? Transjugular intrahepatic portosystemic shunting (TIPS) Vasopressin (Pitressin) Sclerotherapy Balloon tamponade
Transjugular intrahepatic portosystemic shunting (TIPS) A TIPS procedure (see Fig. 49-8) is indicated for the treatment of an acute episode of uncontrolled variceal bleeding refractory to pharmacologic or endoscopic therapy. In 10% to 20% of patients for whom urgent band ligation or sclerotherapy and medications are not successful in eradicating bleeding, a TIPS procedure can effectively control acute variceal hemorrhage by rapidly lowering portal pressure.
