Final
Which factor could cause a high pressure alarm on a ventilator?
Secretions in the endotracheal tube
Which factor increases the risk of developing type 2 diabetes mellitus?
Sedentary lifestyle
Which client is most at risk for developing hyperosmolar hyperglycemia syndrome?
Type 2 diabetes whose blood sugars have been running high
Which client complained could indicate a serious adverse effect of atorvastatin?
Unexplained muscle pain
The nurse is called to a room where a client has collapsed on the floor. The client's heart monitor displays ventricular fibrillation. Which additional finding supports the diagnosis of ventricular fibrillation?
Absent pulse
A client with a diagnosis of diabetes mellitus type 1 is found unresponsive with a blood glucose reading of 30mg/dl. Which nursing action is appropriate?
Administer 1mg of glucagon subcutaneous
The nurse is caring for a client who had barium enema. Which action should the nurse implement?
Administer laxatives as prescribed
Which nursing action requires close monitoring for respiratory depression in a client who is recovering from a laryngectomy?
Administering opiates for pain relief
A client with diabetes type 2 is prescribed a sulfonylurea to control blood glucose levels. What should the client be instructed to avoid while taking the medication?
Alcohol
A patient is diagnosed with an abdominal aortic aneurysm and asks the nurse to explain what an aneurysm is. The most appropriate response by the nurse is:
An aneurysm is a stretching and bulging of the arterial wall of the abdominal aorta
Avoiding which food is the best indication that the client understands dietary restrictions for hypertension?
Beef chili with cheese
When should insulin glargine be administered?
Before meals, adjusted based on blood sugar level.
Which finding in a client with type 2 diabetes is most indicative of the presence of hyperosmolar hyperglycemia syndrome?
Blood glucose is 685 mg/dl
The nurse is reviewing data from a physical examination of a client newly diagnosed with diabetes mellitus. Which finding should the nurse recognize as abnormal?
Blurred vision is reported
The nurse is collecting data from a client suspected of having the syndrome of inappropriate antidiuretic hormone (SIADH). Which findings are considered with this diagnosis?
Bounding pulses, weight gain, concentration urine
A client has a radial pulse of 58 beats per minute. Which of the following should the nurse use to document this finding?
Bradycardia
A client presents with diaphoresis, Palpitations, and tachycardia approximately 4 hours after taking the prescribed dose of insulin. What are the nurse's priority action?
Check the blood glucose and administer carbohydrates
The nurse monitors a client who has a chest infection place to treat pneumothorax for evidence of re-expansion of the lung. Which finding would indicate that the pneumothorax has resolved?
Clear lung sounds in all lung fields
Which nutrient should be included in approximately the same amount with every meal for a client with type 1 diabetes mellitus?
Complex carbohydrates
A client has taken his first dose of lisinopril about 2 hours ago and begins to develop fullness in his face and hoarseness. Which action would the nurse take first?
Determine the client's ability to breathe effectively
A client is scheduled for a 3:00 pm cardiac catheterization today. What is the most important assessment for the nurse to make before the client has a cardiac catheterization?
Determine the status of the pulses of the lower extremities
What type of diabetes is treated with diet, exercise and oral antidiuretic agents?
Diabetes mellitus type 2
The nurse is reviewing dietary instructions with a client who has cushion syndrome. Which client statement indicates an accurate understanding of the teaching?
I can eat food that contain potassium
The nurse is reinforcing teaching to a client who has Cushing's syndrome. Which statement by the client indicates that the instructions related to dietary management were understood?
I can eat foods that contain potassium
The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which client statement should be reported to the health care provider for follow up of possible hyperglycemia?
I have been urinating a lot lately
Which finding are most likely in diabetes mellitus type 1 than in diabetes mellitus type 2?
Kussmaul respirations and acetone breath
Which findings are consistent with a diagnosis of diabetic ketoacidosis?
Kussmaul respirations and acetone breath
A 75 year old client has been admitted for management of worsening dyspnea. The client reports sleeping in the recliner chair for the past three nights due to shortness of breath when lying flat. On examination, the nurse notes crackles in both lung bases, a cough productive of pink, frothy sputum, weak peripheral pulses, and a fast respiratory rate. Which medical diagnosis is the most likely in this client?
Left sided heart failure
Which finding indicates a complication of hypertension?
Left ventricular hypertrophy on chest- x-ray
The nurse is collecting data on a client with a diagnosis of hypothyroidism. Which client complaint may be related to this diagnosis?
Lethargy and mental dullness
Which statement is true about mechanical heart valve replacement?
Lifelong anticoagulant is required
What is the purpose of an expectorant?
Loosens secretions
A client who has Cushing's syndrome was recently admitted from the emergency department with a stab wound to the abdomen. Which potential problem should the nurse recommend receive the highest priority?
Risk for infection
The nurse reinforces teaching with a client with diabetes mellitus about symptoms of hypoglycemia. The client demonstrates an understanding of the teaching by stating the blood sugar will be checked and glucose will be taken if which symptom develops?
Shakiness
Which electrolyte is most likely to be elevated in diabetes insipidus?
Sodium
A nurse auscultates a heart mummur. What is the most likely cause of this finding?
Valve disorder
Which cardiac dysrhythmia will result in cardiac death within minutes if not treated promptly?
Ventricular fibrillation
A client is scheduled for a vascular surgery. The client is taking digoxin, Warfarin, Famotidine, and Furosemide. Which medication may need to be stopped up a week before surgery?
Warfarin
A client diagnosed with pheochromocytoma requests something warm to drink. Which option should the nurse provide?
Warm milk
The nurse is caring for a client at high risk for developing thrombophlebitis. Which findings may indicate the development of this complication?
Warmth, Pain, Redness, edema and palpable venouis cord
The nurse is caring for a client with the syndrome of inappropriate antidiuretic hormone (SIADH). Which data would the nurse expect to collect?
Water retention, history of head injury and Oliguria
Which intervention will help decrease the risk of a hospitalized client developing a deep vein thrombosis?
Wearing support stocking
A client with hypertension arrives for her regular client appointment and tells the nurse, " the feet are killing me. These shoes are so tight." What initial action will the nurse take?
Weigh the client
The nurse is assisting in discharge planning for a client admitted for heart failure. Which instruction should the nurse recommend including in the plan?
Weigh yourself every day
Which condition can result from abrupt withdrawal of long term steroid therapy?
Addisonian crisis
Which finding is considered an age- related change in the cardiovascular system?
Decreased pulse rate
Which intervention is appropriate for the client in ventricular fibrillation?
Defibrillation
Which factor can cause an elevated pulse rate?
Dehydrated
Which factor can cause an elevated pulse rate?
Dehydration
What does QRS complex represent?
Depolarization of ventricles
Which medication is typically prescribed for long- term management of diabetes insipidus?
Desmopressin acetate
Which signs or symptoms are associated with hypothyroidism?
Dry skin and constipation
What EKG change supports the diagnosis that a client is experiencing a myocardial infarction?
Elevated ST segments
What result is expected after injection of a medication to simulate growth hormone production if the pituitary is responding
Elevated growth hormone levels
Which laboratory finding is consistent with a diagnosis of primary hypothyroidism?
Elevated serum TSH, decreased T3 and T4
Which intervention should be included in post- procedure care following a cardiac Catheterization procedure?
Encourage the client to increase fluid intake
Which intervention should be included in post- procedure care following a cardiac catheterization procedure?
Encourage the client to increase fluid intake
Which condition is most likely to cause a serum potassium level of 6.2meQ/L (normal 3.5-5)
End stage renal disease
Which physical change is seen in acromegaly?
Enlarged hands and feet
Which medication is an H2 receptor antagonist (H2 blocker)
Famotidine
The nurse is providing care to a client with cardiomyopathy. Which symptoms, if reported by the client, must be promptly reported to the registered nurse?
Fatigue and Dyspnea
A client with diabetes mellitus has been experiencing frequent episodes of hypoglycemia. Which finding indicate effectiveness of medications adjustments to decrease the frequency these episodes?
Fewer incidences tremors and diaphoresis
A nurse obtaining data from a client observers jugular venous distention. Which condition does the nurse suspect this client to have?
Right sided heart failure
When palpating the abdomen, the nurse would plan to palpate which region last?
Right upper quadrant
Which treatment may be indicated in the management of atrial fibrillation?
Cardioversion - digoxin - anticoagulants
Following a cardiac catheterization in which the femoral vein was accessed. How should the client be positioned in bed?
Head of the bed elevated no more than 30 degrees
Which condition is a complication of all types of cardiomyopathy?
Heart failure
Which heart sound is most associated with a valve disorder in the adult client?
Heart murmur
Which diagnostic test is used to evaluate the effectiveness of glucose control over time?
Hemoglobin A1C
Which finding may indicate damage to the vocal cords following a thyroidectomy?
Hoarseness
Which finding should the nurse expect in a client diagnosed with gastroesophageal disease(GERD)?
Hoarseness
A 27 year old with no significant cardiac history complains of " skipping sensations" while working at home. An electrocardiogram performed in the health provider's (HCP) office shows normal sinus rhythm. What will the HCP most likely prescribed initially to aid in diagnosis?
Holter monitor
The nurse has received several laboratory results. Which one should be reported to the HCP immediately?
Hypocalcemia in a client who just had a thyroidectomy
Which electrolyte imbalance may occur with thiazide diuretics?
Hypokalemia
What modifications of the diet is required for the client who has hypercortisolism ( Cushing syndrome)
Increase potassium
A client is started on levothyroxine to replace thyroxine ( T4) for a new diagnosis of hypothyroidism. What effect is expected as the medication begins to work?
Increased energy
Atropine is administered to a client with an atrial rate of 36 beats per minute. What response will the nurse monitor for?
Increased health rate
Which signs and symptoms are most important for the nurse to investigate in adult clients who are participating in a diabetes screening?
Increased thirst, urination and hunger
The nurse is monitoring a client with diabetes insipidus for therapeutic response to desmopressin acetate. Which finding indicates that treatment has been effective?
Increased urine specific gravity
Which situations could cause diabetic ketoacidosis?
Infection Undiagnosed diabetes mellitus - stress
A client receiving intravenous (IV) fluid therapy complains of pain and a feeling of tightness at the IV insertion site. The site is pale, cool, swollen, and the infusion rate has slowed. The nurse determines which has occurred?
Infiltration
Which hormone lowers blood glucose levels?
Insulin
How is diabetic ketoacidosis treated?
Insulin infusions or injections and fluids
What data is used to monitor a client diagnosed with diabetes insipidus?
Intake and output and daily weight
A client is being treated for atrial fibrillation. The client asks why 81 mg of aspirin daily has been prescribed. What is the most accurate response?
It decreases the risk of blood clots and strokes
The nurse is assisting in the care of a client diagnosed with pericarditis. Which finding should alert the nurse to the development of cardiac tamponade?
- hypotension - muffled heart sounds - jugular venous distention
How should blood glucose levels be routinely monitored by the client with diabetes mellitus?
Performing capillary blood glucose tests with a glucometer several times a day
A client is admitted to the hospital with new onset SIADH. What areas of concern are most important to address in this client? Select all that apply
- knowledge about the disease process - fluid imbalance
What finding is most important to document before a cardiac catheterization procedure?
- prior reaction to contrast dye
What is the onset of action for regular insulin?
30-60 minutes
Which finding is characteristic of right sided heart failure?
Edema
A nurse is collecting data on a client following a cardiac catheterization procedure via the left femoral artery. What data should be collected as part of the neurovascular examination?
- Petal pulse quality
Which initial interventions are anticipated when a client develops acute pulmonary edema?
- Urinary catheter - Oxygen - intravenous diuretics - intravenous morphine
Which intervention is most appropriate for an elderly client who recently started on antihypertensive medication and who experiences dizziness of standing?
- change positions slowly, especially before standing
Which factors can contribute to cardiac arrhythmias?
- electrolyte imbalances - stress - thyroid disorders
The healthcare provider is discharging a client with a diagnosis of primary hypertension. Which health maintenance instructions should the nurse reinforce in the discharge teaching plan? Select all that apply
- fill prescriptions before they run out - Monitor the blood pressure at home - Read food labels for sodium and fat content - Get regularly scheduled opthalmoscopic examinations
The nurse has completed counseling about smoking cessation with a client with coronary artery disease (CAD). The nurse determines that the client has understood the material best if the client makes which statement?
" A smoker is at a higher risk of having a heart attack than a nonsmoker"
The nurse is preparing a client for a thyroidectomy to treat hyperthyroidism. What client statement indicates to the nurse that the client understands the preoperative instructions?
" I may need to take thyroid replacement hormones after surgery."
The nurse is counseling a client with hypothyroidism on drug therapy. Which statement by the client would indicate the additional teaching is needed?
" I will stop taking the medication once I feel better"
An occupational health nurse checks the blood pressure of an employee who has climbed two flights of stairs and obtains a reading of 170/100 mm Hg. What advice should the nurse give this individual?
" Sit down and rest for a while, and then I'll take your blood pressure again."
The nurse asks the UAP to get a set of orthostatic Vital signs on a client who fell 2 days ago. Which instruction is correct?
" Take the blood pressure first when the client is lying down. Then in an upright position."
Which statement made by a client with hypertension indicates a need for further teaching?
" Those blood pressure pills are so expensive. I cut them in half."
The nurse is caring for a client whose blood pressure has consistently been 159 systolic or higher. The client reports feeling fine and questions the need for antihypertensive medication. Which response by the nurse is most helpful?
" Your hypertension may cause organ damage without creating symptoms"
The nurse is reviewing discharge instructions with a client recovering from a hypophysectomy to treat a diagnosis of acromegaly. What should the nurse emphasize with this teaching?
" be sure to take the thyroid hormones corticosteroids, and antidiuretic hormones as prescribed"
A client is complaining of health- related problems. Which finding would the nurse anticipate associated with heart disease? Select all that apply
- Arrhythmias - Dizziness and fatigue . pedal edema
A client has been instructed to maintain a low-sodium diet. The nurse verifies understanding when the client states that these foods should be avoided. Select all that apply.
- Canned soup - Sliced Ham - American cheese
The nurse is caring for a client with a new onset of atrial fibrillation. Which prescribed treatments should the nurse expect?
- Digoxin - Cardioversion - Anticoagulants
The nurse has reinforced teaching about a new diagnosis of hypothyroidism. Which statement by the client indicate that discharge teaching has been effective?
- I have to take my thyroid replacement tables every day - I will call my health care provider if I develop chest pain after starting the levothyroxine - I should increase the amounts of fluids i drink, and add more fiber to my diet.
Which dietary changes are most likely to be recommended for a client who has Addison's disease? Select all that apply
- Increased sodium - increase fluids - Consume adequate amounts of complex carbohydrates
The nurse is assisting in the preparation of a client for a hypophysectomy. What should the nurse emphasize when teaching this client?
- use an incentive spirometer every hour while awake - perform deep breathing exercises - avoid sneezing or forceful nose blowing - avoid bending from the waist
When assessing the neurovascular status on an extremity, which finding would the nurse include in the documentation? Select all that apply
-Presence or absence of pulses - sensation of numbness - Capillary refill time - skin and temperature
Which type of fluid is hypotonic (has a lower osmolality than blood)
0.33% sodium chloride
A client is to receive digoxin 0.125 mg by mouth. The pharmacy sends digoxin 125 mcg tables. How many tablets should the client receive?
1
Which option should the nurse instruct the UAP to provider to a client with diabetes mellitus when distributing evening snacks?
1/2 peanut butter sandwich on whole wheat bread
100 ml of dextrose 5% in 0.45% sodium chloride to infuse over 45 minutes. What is the hourly rate? Round to the nearest whole number if needed
100ml Time to infuse: 45 minutes Minutes in an hour:60 100/45= X60/1 hour= 133
A client's weight is recorded as 84kg on a routine visit. The client asks how much this is in " real weight" What will the nurse report as the client's weight in pounds. Round to the nearest whole number.
185
A client is being treated for diabetic ketoacidosis. Which pH value would be an expected finding for this diagnosis?
7.28
A client's chest tube drainage system contained 150ml of sanguineous fluid at the start of the shift. There was 225ml in the drainage chamber at the end of the shift. What should the nurse record as the drainage output for the shift?
75
A client received insulin lispro 15 units before breakfast, but did not eat. When should the nurse most closely monitor for hypoglycemia?
30 to 90 mins
A client's reported weight is 198 pounds. How much does the client weigh in kg?
90
A client's stroke volume is calculated to be 65 mL per beat, and the heart rate is 82 beats per minute. What is the client's cardiac output? Record your answer in liters per minute. Liters per minute. Round to the nearest 10th of a liter.
5.3
Which client is most likely to be a candidate for a permanent pacemaker?
A 78- year old client with persistent bradycardia and syncopal episodes
The nurse is participating in a care conference on clients with diabetes mellitus who live in a group home. For which client should the nurse recommend a change in treatment plan?
A client whose last last hemoglobin A12 was 12% (Normal less than 5.7%)
The nurse is working in an endocrinology unit. Which client warrants immediate intervention by the RN?
A post- operative client following a thyroidectomy who develops laryngeal stridor.
The nurse has received shift reports on four client. Which client should the nurse see first?
A client with hypothyroidism with a heart rate of 48 beats per minute
Which collecting data on a client with Cushing's disease, the nurse obtains a temperature reading of 100.8 F. How should the nurse interpret this result?
Abnormal, needs to be reported immediately
A client is receiving digoxin daily. Which symptom should the nurse report for follow up- related to the digoxin?
Anorexia
The nurse is assisting in the care of a client who reports difficulty breathing. Which finding is an early sign of hypoxia?
Anxiety
The nurse is instructing a client on side effects of levothyroxine to report. What side effects should be included? Select all that apply
Anxiety - Insomnia - Mild heat intolerance
Which data is most important to collect before administering digoxin to an adult being treated for atrial fibrillation?
Apical pulse
The nurse is collecting data on a client who is recovering from a thyroidectomy. Which finding should be reported immediately to the HCP?
Apical pulse of 120 beats per minute
A client who develops chest pain that radiates down the left arm has all of these measures prescribed. Which one should the nurse do first?
Apply oxygen 2L/min
A client has been admitted with a diagnosis of myxedema coma. Which treatment order should be implemented FIRST?
Apply oxygen at 15 LPM by non- rebreather mask
When monitoring for complications following a femoral popliteal bypass surgery, the nurse performs neurovascular checks at routine intervals. What is included in a neurovascular check?
Asking about numbness or tingling
A hospitalized client with a history of angina pectoris is ambulating in the corridor. The client suddenly complains of severe substernal chest pain. Which action should the nurse take first?
Assist the client to sit or lie down
Which finding may be a complication of anticoagulant therapy?
Asymptomatic hematuria
A 67 year- old client has been admitted to the hospital following a syncopal episode. The client is alert, oriented, and pain free but reports palpitations. The vital signs are stable, but the pulse is irregularly irregular. Which cardiac rhythm would the nurse expect the client to the experiencing?
Atrial fibrillation
The nurse is reinforcing teaching for a client who has a new diagnosis of peripheral arterial disease (PAD). Which recommendation should the nurse make?
Avoid elevating the legs as much as possible
The nurse is reinforcing the teaching provided to a client with Raynaud's phenomenon. Which measure should the nurse include to prevent an attack?
Avoid smoking, caffeine or exposure to cold
A client presents with diaphoresis, palpitations, and tachycardia approximately 4 hours after taking the prescribed dose of insulin. What are the nurses priority actions?
Check the blood glucose and administer carbohydrate
The nurse is preparing a client for a cardiac catheterization procedure, which allergy should the nurse specifically ask about?
Contract dyes
Which finding is a common side effect of enalapril?
Cough
A client with myocardial infarction suddenly becomes tachycardic, shows signs of air hunger, begins coughing frosty, pink-tinged sputum. The nurse listens to breathe sounds expecting to hear which breathe sounds bilaterally?
Crackles
What age related changes occur to the respiratory system?
Decreased elastic recoil - weaker cough
The nurse is reinforcing teaching about self-care for a newly diagnosed with diabetes mellitus type 1. What information should be included? Select all that apply
Dietary compliance, insulin administration, foot care and signs of hypoglycemia
What is an aneurysm?
Dilation of a weakened area in the artery wall
A glucocorticoid is prescribed for a client with adrenal insufficiency, and the nurse reinforces medication instructions to the client. The nurse determines that the client needs further teaching if the client states which action is necessary?
Discontinue the medication when symptoms subside
A client is being discharged following pacemaker insertion. The nurse is reinforcing prior to discharge. The nurse determines that teaching has been effective if the client makes which statement?
Dizziness or weakness should be reported to my healthcare provider.
An ambulance clinic nurse is interviewing a client who is complaining of flulike symptoms. The client suddenly develops chest pain. Which question best assists the nurse to discriminate pain caused by a noncardiac problem?
Does the pain get worse when you breathe in
A client newly diagnosed with type 1 diabetes mellitus is learning about diabetic foot care. The nurse would instruct the client to avoid
Foot soaks
The patient who ordered a low-sodium diet. The nurse knows that the patient understood the limitations when the meal she ordered contained:
Fresh turkey sandwich and fresh orange slices
Which finding heart on auscultation is most indicate of pericarditis?
Friction rub
A client with diabetes mellitus is seen for a follow up visit. Which information is most important to evaluate the effectiveness of the therapeutic regimen?
Glucose monitoring records for the past week
Which insulin's are rapid acting?
Glulisine, Lispro, Aspart
A 12 year old child is six feet tall. What hormone will the HCP most likely measure?
Growth hormone
The nurse is collecting data on a client who is recovering following a thyroidectomy. Which finding would be the most concerning?
Hand cramps when the blood pressure is taken
Which food option is a simple sugar appropriate to treat hypoglycemia?
Hard candies
The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diabetic diet. Which statement made by the client indicates accurate understanding of the teaching?
I will eat approximately the same amount of carbohydrates at each meal
The nurse becomes concerned that a client's blood pressure is 168/98 mm HG after 6 months on antihypertensive medication. What additional information should the nurse obtain after measuring this blood pressure?
If the client is taking the medication
The nurse cares for a client with a history of COPD who has received steroid therapy for several years. Which physical changes would the client most likely exhibit?
Moon face, truncal obesity, buffalo hump.
The nurse cares for a client with a history of COPD who has received steroid therapy for several years. Which physical changes would the client most likely exhibit?
Moon face, truncal obesity, buffalo lump
The nurse is discharging a client from the hospital who has given a prescription for atorvastatin. The nurse would tell the client to report which adverse effect to the primary health care provider immediately?
Muscle pain and weakness
Which finding would indicate that cardioversion has been successful?
Normal sinus cardiac rhythm is restored
What is the physiologic cause of Cushing's syndrome?
Overproduction of corticosteroids
The nurse is assisting in the care of a client following cardioversion. Which finding requires notification of the registered nurse?
Oxygen saturation of 88% on room air
Which blood gas result indicates respiratory acidosis?
PaCO2 53 mm Hg ( reference 35-45mm Hg)
Why does the nurse check a finger stick blood sugar every 4-6 hours on a client receiving parenteral nutrition?
Parenteral nutrition can cause hyperglycemia
A client who is 40 pounds overweight, smokes 3/4 pack of cigarettes a day, and is being treated for elevated cholesterol levels reports cramping pain in both legs that occurs with walking but goes away when the client stops to rest for a few minutes. What parameter should the nurse check next related to the client's complaint?
Pedal pulse quality
A client has been newly diagnosed with Type 2 diabetes mellitus. What nursing observation would correlate with this diagnosis?
Polyuria
A client has been newly diagnosed with type 2, diabetes mellitus. What nursing observation would correlate with this diagnosis?
Polyuria
After reviewing a client's history and physical examination, which symptoms would lead the nurse to suspect hyperglycemia?
Polyuria, Polyphagia, and polydipsia
What are the most common signs and symptoms of hyperglycemia?
Polyuria, polydipsia, polyphagia
Serum level of 6.2 mg/dl, diagnosed with hyperparathyroidism
Positive Chvostek sign
Which laboratory value should be closely monitored in the client taking hydrochlorothiazide?
Potassium
Which medication, when stopped abruptly, can precipitate an addisonian crisis?
Prednisone
Which determination is necessary before administering radioactive iodine to a female client?
Pregnancy
Why are B12 injections administered to a client who has had a total gastrectomy?
Prevents pernicious anemia
A young client has uncontrolled diabetes and is admitted to the hospital with severe hyperglycemia. The nurse understands that failure to recognizes a serious complication of this condition would result in the client developing
Progressive dehydration
Which intervention will be the most effective in providing a therapeutic environment for the client with Grave's disease?
Providing a calm, restful environment
A client diagnosed with thrombophlebitis 1 day ago suddenly complains of chest pain and shortness of breath, the client is visibly anxious. Which life threatening complication is most likely occurring?
Pulmonary embolism
The nurse is performing an abdominal assessment on a client. The nurse interprets that which finding is abnormal and would be immediately reported?
Pulsating abdominal mass
Which waveform represents ventricular depolarization?
QRS complex
The nurse is caring for a client following a thyroidectomy and notes that the client's voice is weak and hoarse. The client's vital signs are within the pre-operative range, and the client's skin is warm and dry. Which nursing action is appropriate at this time?
Reassure the client that this is usually a temporary condition
The nurse is assisting in the care of a client who has heart failure. What is the focus of nursing management for this client?
Reduce intravascular fluid volume
The nurse is reinforcing teaching for a client newly diagnosed with diabetes mellitus type 2. Which client statement about the relationship between diabetes and exercise indicates that the client understood the instructions?
Regular aerobic exercise will help control my blood sugar levels
A client is admitted for blood pressure control prior to surgery to remove a pheochromocytoma. Before delivering the breakfast tray, which item should be removed?
Regular coffee
The health care provider has prescribed several medications for a client expected diabetic ketoacidosis (DKA) what is the primary medication administered to treat DKA?
Regular insulin
A client is scheduled for an upper GI series (barium swallow) which nursing intervention is the priority for this client?
Remind the client not to eat or drink anything before the procedure
A client develops phlebitis at the IV insertion site. What action should the nurse take?
Remove the IV and restart in the other arm
A patient is suspected of having active TB. The nurse explains that which test will verify that the disease is in the " active state."
Sputum culture
Which test will confirm a diagnosis of tuberculosis disease (active tuberculosis)?
Sputum culture
The nurse has reinforced teaching about the potential complications of hypertension. Which complication, if identified by the client, indicates that has the teaching has been effective?
Stroke
What findings are consistent with hypo glycemia?
Tachycardia, tremors, cool, clammy skin
A client who returned to the nursing unit 8 hours ago after hypophysectomy has clear drainage saturating the nasal dressing. What action should the nurse take?
Test the drainage for glucose
The nurse is observing an unlicensed assistive person (UAP) obtaining a blood pressure reading in the long-term care facility. The nurse should intervene if which action were noted?
The UAP engages the client in conversation which checking the blood pressure
The nurse is collecting data from a client with type 2 diabetes mellitus. Which statement by the client indicates an understanding of the medication regimen?
The medication that I am taking helps release the insulin I already make.
Which finding is likely in crushing syndrome?
Thin, easily damaged skin
A client diagnosed with a large left pleural effusion has not improved after 24 hours of supportive treatment. Breathe sounds are diminished on the left. What procedure should the nurse plan to assist with?
Thoracentesis
Which factors can contribute to cardiac arrhythmias?
Thyroid disorders - stress - electrolyte imbalance
A client is returning to the room following a thyroidectomy. Which piece of equipment should the nurse place at the bedside?
Tracheotomy set
The nurse is monitoring a client who received rapid-acting insulin 2 hours ago. What signs or symptoms should alert the nurse to possible hypoglycemia?
Tremors, Hunger and Diaphoresis
The nurse is reviewing laboratory test results for a client who may have hyperthyroidism. The nurse should identify an elevated in which of the following levels as indicating that the client has this disorder?
Triiodothyronine T3
The nurse is assisting in the care of a client who has had chest pain for four days. Several lab tests are ordered. Which one would most likely be elevated if the client had experienced a myocardial infarction more than 3 days ago?
Troponin-I
Which foods should be eaten in moderation by clients taking warfarin sodium to prevent clot formation?
Turnip greens and spinach
A client who weights 285 pounds needs to have a blood pressure measurement. Which modification is necessary to obtain an accurate pressure on this client?
Use a larger cuff
Which substance should be avoided before a cardiac stress test?
caffeine
What does an electrocardiogram measure?
electrical activity of the heart
Hypophysectomy
removal of the pituitary gland ( located just below the hypothalamus in the brain)
