HIM EXAM 3
A nurse assesses a client with a fungal urinary tract infection (UTI). Which assessments should the nurse complete? (Select all that apply.) a. Palpate the kidneys and bladder. b. Assess the medical history and current medical problems c. Perform a bladder scan to assess post-void residual d. Inquire about recent travel to foreign countries. e. Obtain a current list of medications.
-Assess the medical history and current medical problems -Obtain a current list of medications.
A nurse teaches a client about self-care after experiencing a urinary calculus treated by lithotripsy. Which statements should the nurse include in this clients discharge teaching? (Select all that apply.) a. Finish the prescribed antibiotic even if you are feeling b. Drink at least 3 liters of fluid each day c.The bruising on your back may take several weeks to resolve. d. Report any blood present in your urine. e. It is normal to experience pain and difficulty urinating
-Finish the prescribed antibiotic even if you are feeling -Drink at least 3 liters of fluid each day -The bruising on your back may take several weeks to resolve.
A nurse assesses a client who has had two episodes of bacterial cystitis in the last 6 months. Which questions should the nurse ask? (Select all that apply.) a. How much water do you drink every day? b. Do you take estrogen replacement therapy? c. Does anyone in your family have a history of cystitis? d. Are you on steroids or other immune-suppressing drugs? e. Do you drink grapefruit juice or orange juice daily?
-How much water do you drink every day? -Do you take estrogen replacement therapy? -Are you on steroids or other immune-suppressing drugs?
A nurse teaches a client with a history of calcium phosphate urinary stones. Which statements should the nurse include in this clients dietary teaching? (Select all that apply.) a. Limit your intake of food high in animal protein. b. Read food labels to help minimize your sodium intake. c. Avoid spinach, black tea, and rhubarb d. Drink white wine or beer instead of red wine e. Reduce your intake of milk and other dairy products
-Limit your intake of food high in animal protein. -Read food labels to help minimize your sodium intake. -Reduce your intake of milk and other dairy products
A nurse assesses clients on the medical-surgical unit. Which clients are at risk for kidney problems? (Select all that apply.) a. A 24-year-old pregnant woman prescribed prenatal vitamins b. A 32-year-old bodybuilder taking synthetic creatine supplements c. A 56-year-old who is taking metformin for diabetes mellitus d. A 68-year-old taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic back pain e. A 75-year-old with chronic obstructive pulmonary disease (COPD) who is prescribed an albuterol nebulizer
32-year-old bodybuilder taking synthetic creatine supplements A 56-year-old who is taking metformin for diabetes mellitus A 68-year-old taking high-dose nonsteroidal anti-inflammatory drugs (NSAIDs) for chronic back pain
A nurse is instructing a client who is scheduled for a transurethral resection of the prostate (TURP) about postoperative care. Which of the following information should the nurse include in the teaching? A. "You might have a continuous sensation of needing to void even though you have a catheter." B. "You will be on bed rest for the first 2 days after the procedure." C. "You will be instructed to limit your fluid intake after the procedure." D. Your urine should be clear yellow the evening after the surgery."
A
A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of bacterial cystitis? a. A 36-year-old female who has never been pregnant b. A 42-year-old male who is prescribed cyclophosphamide c. A 58-year-old female who is not taking estrogen replacement d. A 77-year-old male with mild congestive heart failure
A 58-year-old female who is not taking estrogen replacement
A nurse at a provider/s office is caring for an older adult client who is having annual physical exam. Which of the following findings is needed in regard to the prostate gland? Select all that apply A. Prostate specific antigen ( PSA) is 7.1 ng/mL B. A digital rectal exam (DRE) reveals an enlarged and nodular prostate C. The client reports a weak urine stream D. The client reports urinating once during the night E. Smegma is present below the glans of the penis
A, B, C
A nurse provides diabetic education at a public health fair. Which disorders should the nurse include as complications of diabetes mellitus? (Select all that apply.) a. Stroke b. Kidney failure c. Blindness d. Respiratory failure e. Cirrhosis
A, B, C
A nurse is reviewing discharge instructions with a client who had spontaneous passage of a calcium phosphate renal calculus. Which of the following instructions should the nurse include in the teaching? Select all that apply A. Limit intake of food high in animal protein B. Reduce sodium intake C. Strain urine for 48 hr D. Report burning with urination to the provider E. Increase fluid intake to 3 L/day
A, B, D, E
A nurse assesses a client who is experiencing a cluster headache. Which clinical manifestations should the nurse expect to find? (Select all that apply.) a. Ipsilateral tearing of the eye b. Miosis c. Abrupt loss of consciousness d. Neck and shoulder tenderness e. Nasal congestion f. Exophthalmos
A, B, E
A nurse plans care for an older adult client. Which interventions should the nurse include in this clients plan of care to promote kidney health? (Select all that apply.) a. Ensure adequate fluid intake. b. Leave the bathroom light on at night. c. Encourage use of the toilet every 6 hours. d. Delegate bladder training instructions to the unlicensed assistive personnel (UAP). e. Provide thorough perineal care after each voiding. f. Assess for urinary retention and urinary tract infection.
A, B, E, F
A nurse teaches a client with diabetes mellitus about foot care. Which statements should the nurse include in this clients teaching? (Select all that apply.) a. Do not walk around barefoot. b. Soak your feet in a tub each evening. c. Trim toenails straight across with a nail clipper. d. Treat any blisters or sores with Epsom salts. e. Wash your feet every other day.
A, C
A nurse evaluates the results of diagnostic tests on a clients cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) a. Clear b. Cloudy c. Increased protein level d. Normal glucose level e. Bacterial organisms present f. Increased white blood cells
A, C, D
. A nurse on the postoperative unit administers many opioid analgesics. What actions by the nurse are best to prevent unwanted sedation as a complication of these medications? (Select all that apply.) a. Avoid using other medications that cause sedation. b. Delay giving medication if the client is sleeping. c. Give the lowest dose that produces good control. d. Identify clients at high risk for unwanted sedation. e. Use an oximeter to monitor clients receiving analgesia.
A, C, D, E
A client has been diagnosed with Bells palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.) a. Acyclovir (Zovirax) b. Carbamazepine (Tegretol) c. Famciclovir (Famvir) d. Prednisone (Deltasone) e. Valacyclovir (Valtrex)
A, C, D, E
A nurse assesses a client who is experiencing diabetic ketoacidosis (DKA). For which manifestations should the nurse monitor the client? (Select all that apply.) a. Deep and fast respirations b. Decreased urine output c. Tachycardia d. Dependent pulmonary crackles e. Orthostatic hypotension
A, C, E
A nurse is preparing educational material to present to a female client who has frequent urinary tract infections. Which of the following information should the nurse include. Select all that apply A. Avoid sitting in a wet bathing suit B. Wipe the perineal area back to front following elimination C. Empty the bladder when there is an urge to void D. Wear synthetic fabric underwear E. Take shower daily
A, C, E
A faculty member explains the concepts of addiction, tolerance, and dependence to students. Which information is accurate? (Select all that apply.) a. Addiction is a chronic physiologic disease process. b. Physical dependence and addiction are the same thing. c. Pseudoaddiction can result in withdrawal symptoms. d. Tolerance is a normal response to regular opioid use. e. Tolerance is said to occur when opioid effects decrease.
A, D, E
1.A nurse assesses clients at a health fair. Which clients should the nurse counsel to be tested for diabetes? (Select all that apply.) a. 56-year-old African-American male b. Female with a 30-pound weight gain during pregnancy c. Male with a history of pancreatic trauma d. 48-year-old woman with a sedentary lifestyle e. Male with a body mass index greater than 25 kg/m2 f. 28-year-old female who gave birth to a baby weighing 9.2 pounds
A, D, E, F
A nurse plans care for a client with epilepsy who is admitted to the hospital. Which interventions should the nurse include in this clients plan of care? (Select all that apply.) a. Have suction equipment at the bedside. b. Place a padded tongue blade at the bedside. c. Permit only clear oral fluids. d. Keep bed rails up at all times. e. Maintain the client on strict bedrest. f. Ensure that the client has IV access.
A, D, F
A new nurse reports to the precepting nurse that a client requested pain medication, and when the nurse brought it, the client was sound asleep. The nurse states the client cannot possibly sleep with the severe pain the client described. What response by the experienced nurse is best? a. Being able to sleep doesnt mean pain doesnt exist. b. Have you ever experienced any type of pain? c. The client should be assessed for drug addiction. d. Youre right; I would put the medication back.
A. Being able to sleep doesn't mean pain doesn't exist
What other medical conditions would the nurse expect to see in a patient with restless leg syndrome? A. Diabetes and kidney failure B. Myasthenia gravis and decreased vision C. Trigeminal neuralgia and facial paralysis D. Peripheral vascular disease and multiple sclerosis
A. Diabetes and kidney failure
After teaching a client with bacterial cystitis who is prescribed phenazopyridine (Pyridium), the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I will not take this drug with food or milk. b. If I think I am pregnant, I will stop the drug. c. An orange color in my urine should not alarm me. d. I will drink two glasses of cranberry juice daily
An orange color in my urine should not alarm me
A client has trigeminal neuralgia and has begun skipping meals and not brushing his teeth, and his family believes he has become depressed. What action by the nurse is best? a. Ask the client to explain his feelings related to this disorder. b. Explain how dental hygiene is related to overall health. c. Refer the client to a medical social worker for assessment. d. Tell the client that he will become malnourished in time.
Ask the client to explain his feelings related to this disorder.
A nurse cares for a client with an increased blood urea nitrogen (BUN)/creatinine ratio. Which action should the nurse take first? a. Assess the clients dietary habits. b. Inquire about the use of nonsteroidal anti-inflammatory drugs (NSAIDs). c. Hold the clients metformin (Glucophage) d. Contact the health care provider immediately
Assess the clients dietary habits
A nurse is providing discharge instructions to a client who is postoperative following a TURP. Which of the following instructions should the nurse include? Select all that apply. A. Avoid sexual intercourse for 3 months after surgery B. If urine appears bloody, stop activity and rest C. Avoid drinking caffeinated beverages D. Take a stool softener once a day. E. Treat pain with ibuprofen
B, C, D
A nurse in a provider's office is obtaining a history from a client who is undergoing an evaluation for benign prostatic hyperplasia (BPH). The nurse should identify that which of the following findings are indicative of this condition? Select all that apply. A. Backache B. Frequent urinary tract infections C. Weight loss D. Hematuria E. Urinary incontinence
B, D, E
A nurse is teaching a client who has chronic headaches. Which statements about headache triggers should the nurse include in this clients plan of care? (Select all that apply.) a. Increase your intake of caffeinated beverages. b. Incorporate physical exercise into your daily routine. c. Avoid all alcoholic beverages. d. Participate in a smoking cessation program. e. Increase your intake of fruits and vegetables.
B, D, E
A nurse is teaching a client who is recovering from pancreatitis about following a low fat diet. Which of the following foods should the nurse recommend? Select all that apply A. Ribeye steak B. Oatmeal C. Icecream D. Canned peaches E. Pretzesl
B, D, E
A nurse is assessing a client who is postoperative from a gastric bypass and who just finished eating a meal. Which of the following findings are manifestations of dumping syndrome? Select all that apply A. Bradycardia B. Dizziness C. Dry skin D. Hypotension E. Diarrhea
B, D< E
A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) a. Photophobia b. Dilated pupils c. Headache d. Widened pulse pressure e. Bradycardia
B,D, E
The nurse is caring for a patient with a diagnosis of Bell's palsy. The nurse understands that for a patient with Bell's palsy the symptoms are the most severe during which time period after beginning? A. 12 hours after onset B. 48 hours after onset C. 96 hours after onset D. 1 to 2 weeks after onset
B. 48 hours after onset
A nurse is completing the admission assessment of a client who has renal calculi. Which of the following findings should the nurse expect? A. Bradycardia B. Diaphoresis C.Nocturia D. Bradypnea
B. Diaphoresis
A nurse is reviewing urinalysis results for four clients. Which of the following urinalysis results indicates a urinary tract infection? A. Positive for hyaline casts B. Positive for leukocyte esterase C. Positive for ketones D. Positive for crystals
B. Positive for leukocyte esterase
A nurse is completing discharge instructions with a client who has spontaneously passed a calcium oxalate calculus. To decrease the chance of recurrence, the nurse should instruct the client to avoid which of the following foods? Select all that apply A. Red meat B. Black tea C. Cheese D. Whole grains E. Spinach
Black tea and spinach
A nurse is teaching a client who has constipation about a high fiber low fat diet. Which of the following food choices by the client indicates an understanding of the teaching? A. Peanut butter B. Peeled apples C. Hardboiled egg D. Brown rice
Brown rice
A nurse is caring for a client who has a left renal calculus and an indwelling urinary catheter. Which of the following assessment findings is the priority for the nurse to report to the provider? A. Flank pain that radiates to the lower abdomen B. Client report of nausea C. Absent urine output for 1 hr D. Blood wbc count 15,000
C. Absent urine output for 1 hr
A nurse is providing information to a client who is schedules for a transrectal ultrasound (TRUS). Which of the following information should the nurse include? A. "This procedure will determine whether you have prostate cancer." B. " The procedure is contraindicated if you have an allergy to eggs." C. "Sound waves will be used to create a picture of your prostate." D. "You should avoid having a bowel movement for 1 hr prior to the procedure."
C. Sound waves will be used to create a picture of your prostate
A nurse is caring for a client who has a new diagnosis of benign prostatic hyperplasia (BPH). The nurse should expect a prescription for which of the following medications? A. Oxybutynin B. Diphenhydramine C. Ipratropium D. Tamsulosin
D
A nurse is caring for a client who has a urinary tract infection. Which of the following is a priority intervention by the nurse? A. Offer a warm sitz bath B. Recommend drinking cranberry juice C. Encourage increased fluids D. Administer an antibiotic
D. Administer an antibiotic
A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best? a. Numeric pain scale b. Behavioral assessment c. Objective observation d. Clients self-report
D. Clients self-report
A client in the family practice clinic has restless leg syndrome. Routine laboratory work reveals white blood cells 8000/mm3, magnesium 0.8 mEq/L, and sodium 138 mEq/L. What action by the nurse is best? a. Advise the client to restrict fluids. b. Assess the client for signs of infection. c. Have the client add table salt to food. d. Instruct the client on a magnesium supplement.
D. Instruct the client on a magnesium supplement
A nurse assesses a client recovering from a cystoscopy. Which assessment findings should alert the nurse to urgently contact the health care provider? (Select all that apply.) a. Decrease in urine output b. Tolerating oral fluids c. Prescription for metformin d. Blood clots present in the urine e. Burning sensation when urinating
Decrease in urine output Blood clots present in the urine
A nurse reviews the urinalysis results of a client and notes a urine osmolality of 1200 mOsm/L. Which action should the nurse take? a. Contact the provider and recommend a low-sodium diet. b. Prepare to administer an intravenous diuretic. c. Obtain a suction device and implement seizure precautions. d. Encourage the client to drink more fluids
Encourage the client to drink more fluids
A nurse cares for a client with a urine specific gravity of 1.040. Which action should the nurse take? a. Obtain a urine culture and sensitivity. b. Place the client on restricted fluids c. Assess the clients creatinine level d.Increase the clients fluid intake
Increases the clients fluid intake
A nurse contacts the health care provider after reviewing a clients laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription? a. Intravenous fluids b. Hemodialysis c. Fluid restriction d. Urine culture and sensitivity
Intravenous fluids
A nurse cares for a postmenopausal client who has had two episodes of bacterial urethritis in the last 6 months. The client asks, I never have urinary tract infections. Why is this happening now? How should the nurse respond? a. Your immune system becomes less effective as you age. b. Low estrogen levels can make the tissue more susceptible to infection. c. You should be more careful with your personal hygiene in this area d. It is likely that you have an untreated sexually transmitted disease
Low estrogen levels can make the tissue more susceptible to infection
A nurse provides phone triage to a pregnant client. The client states, I am experiencing a burning pain when I urinate. How should the nurse respond? a. This means labor will start soon. Prepare to go to the hospital. b. You probably have a urinary tract infection. Drink more cranberry juice. c. Make an appointment with your provider to have your infection treated. d. Your pelvic wall is weakening. Pelvic muscles should help
Make an appointment with your provider to have your infection treated.
A nurse reviews the laboratory findings of a client with a urinary tract infection. The laboratory report notes a shift to the left in a clients white blood cell count. Which action should the nurse take? a. Request that the laboratory perform a differential analysis on the white blood cells. b. Notify the provider and start an intravenous line for parenteral antibiotics. c. Collaborate with the unlicensed assistive personnel (UAP) to strain the clients urine for renal calculi. D.Assess the client for a potential allergic reaction and anaphylactic shock?
Notify the provider and start and start an intravenous line for parenteral antibiotics
A nurse reviews the urinalysis of a client and notes the presence of glucose. Which action should the nurse take? a. Document findings and continue to monitor the client b.Contact the provider and recommend a 24-hour urine test. c. Review the clients recent dietary selections. d.Perform a capillary artery glucose assessmeent
Perform a capillary artery glucose assessment
A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.) a. Particulate respirator b. Isolation gown c. Shoe covers d. Surgical mask e. Gloves
Surgical mask gloves, gown
18. A nurse teaches a young female client who is prescribed amoxicillin (Amoxil) for a urinary tract infection. Which statement should the nurse include in this clients teaching? a. Use a second form of birth control while on this medication. b. You will experience increased menstrual bleeding while on this drug. c. You may experience an irregular heartbeat while on this drug. d. Watch for blood in your urine while taking this medication.
Use a second form of birth control while on this medication.
A nurse assesses a client who has diabetes mellitus and notes the client is awake and alert, but shaky, diaphoretic, and weak. Five minutes after administering a half-cup of orange juice, the clients clinical manifestations have not changed. Which action should the nurse take next? a. Administer another half-cup of orange juice. b. Administer a half-ampule of dextrose 50% intravenously. c. Administer 10 units of regular insulin subcutaneously. d. Administer 1 mg of glucagon intramuscularly.
a. Administer another half-cup of orange juice.
A postoperative client is reluctant to participate in physical therapy. What action by the nurse is best? a. Ask the client about pain goals and if they are being met. b. Ask the client why he or she is being uncooperative with therapy. c. Increase the dose of analgesia given prior to therapy sessions. d. Tell the client that physical therapy is required to regain function.
a. Ask the client about pain goals and if they are being met.
A nurse uses the Checklist of Nonverbal Pain Indicators to assess pain in a nonverbal client with advanced dementia. The client scores a zero. What action by the nurse is best? a. Assess physiologic indicators and vital signs. b. Do not give pain medication as no pain is indicated. c. Document the findings and continue to monitor. d. Try a small dose of analgesic medication for pain.
a. Assess physiologic indicators and vital signs
A nurse assesses a client who is prescribed a medication that inhibits angiotensin I from converting into angiotensin II (angiotensin-converting enzyme [ACE] inhibitor). For which expected therapeutic effect should the nurse assess? a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg b. Daily weight increase from 55 kg to 57 kg c. Heart rate decrease from 100 beats/min to 82 beats/min d. Respiratory rate increase from 12 breaths/min to 15 breaths/min
a. Blood pressure decrease from 180/72 mm Hg to 144/50 mm Hg
A nurse obtains a focused health history for a client who is suspected of having bacterial meningitis. Which question should the nurse ask? a. Do you live in a crowded residence? b. When was your last tetanus vaccination? c. Have you had any viral infections recently? d. Have you traveled out of the country in the last month?
a. Do you live in a crowded residence?
A preoperative nurse assesses a client who has type 1 diabetes mellitus prior to a surgical procedure. The clients blood glucose level is 160 mg/dL. Which action should the nurse take? a. Document the finding in the clients chart. b. Administer a bolus of regular insulin IV. c. Call the surgeon to cancel the procedure. d. Draw blood gases to assess the metabolic state.
a. Document the finding in the clients chart.
.A nurse prepares to administer insulin to a client at 1800. The clients medication administration record contains the following information: Insulin glargine: 12 units daily at 1800 Regular insulin: 6 units QID at 0600, 1200, 1800, 2400 Based on the clients medication administration record, which action should the nurse take? a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin. b. Draw up and inject the insulin glargine first, wait 20 minutes, and then draw up and inject the regular insulin. c. First draw up the dose of regular insulin, then draw up the dose of insulin glargine in the same syringe, mix, and inject the two insulins together. d. First draw up the dose of insulin glargine, then draw up the dose of regular insulin in the same syringe, mix, and inject the two insulins together.
a. Draw up and inject the insulin glargine first, and then draw up and inject the regular insulin.
The nurse receives a hand-off report. One client is described as a drug seeker who is obsessed with even tiny changes in physical condition and is on the light constantly asking for more pain medication. When assessing this clients pain, what statement or question by the nurse is most appropriate? a. Help me understand how pain is affecting you right now. b. I wish I could do more; is there anything I can get for you? c. You cannot have more pain medication for 3 hours. d. Why do you think the medication is not helping your pain?
a. Help me understand how pain is affecting you right now.
.An emergency department nurse assesses a client with ketoacidosis. Which clinical manifestation should the nurse correlate with this condition? a. Increased rate and depth of respiration b. Extremity tremors followed by seizure activity c. Oral temperature of 102 F (38.9 C) d. Severe orthostatic hypotension
a. Increased rate and depth of respiration
A nurse prepares a client for a percutaneous kidney biopsy. Which actions should the nurse take prior to this procedure? (Select all that apply.) a. Keep the client NPO for 4 to 6 hours. b. Obtain coagulation study results. c. Maintain strict bedrest in a supine position. d. Assess for blood in the clients urine. e. Administer antihypertensive medications.
a. Keep the client NPO for 4 to 6 hours. b. Obtain coagulation study results. e. Administer antihypertensive medications.
An emergency department (ED) manager wishes to start offering clients nonpharmacologic pain control methodologies as an adjunct to medication. Which strategy would be most successful with this client population? a. Listening to music on a headset b. Participating in biofeedback c. Playing video games d. Using guided imagery
a. Listening to music on a headset
A nurse teaches a client who is diagnosed with diabetes mellitus. Which statement should the nurse include in this clients plan of care to delay the onset of microvascular and macrovascular complications? a. Maintain tight glycemic control and prevent hyperglycemia. b. Restrict your fluid intake to no more than 2 liters a day. c. Prevent hypoglycemia by eating a bedtime snack. d. Limit your intake of protein to prevent ketoacidosis.
a. Maintain tight glycemic control and prevent hyperglycemia.
After teaching a client with diabetes mellitus to inject insulin, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. The lower abdomen is the best location because it is closest to the pancreas. b. I can reach my thigh the best, so I will use the different areas of my thighs. c. By rotating the sites in one area, my chance of having a reaction is decreased. d. Changing injection sites from the thigh to the arm will change absorption rates.
a. The lower abdomen is the best location because it is closest to the pancreas.
.A nurse cares for a client with diabetes mellitus who is visually impaired. The client asks, Can I ask my niece to prefill my syringes and then store them for later use when I need them? How should the nurse respond? a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up. b. Yes. Syringes can be filled with insulin and stored for a month in a location that is protected from light. c. Insulin reacts with plastic, so prefilled syringes are okay, but you will need to use glass syringes. d. No. Insulin syringes cannot be prefilled and stored for any length of time outside of the container.
a. Yes. Prefilled syringes can be stored for 3 weeks in the refrigerator in a vertical position with the needle pointing up.
A nurse cares for a client who has a family history of diabetes mellitus. The client states, My father has type 1 diabetes mellitus. Will I develop this disease as well? How should the nurse respond? a. Your risk of diabetes is higher than the general population, but it may not occur. b. No genetic risk is associated with the development of type 1 diabetes mellitus. c. The risk for becoming a diabetic is 50% because of how it is inherited. d. Female children do not inherit diabetes mellitus, but male children will.
a. Your risk of diabetes is higher than the general population, but it may not occur.
A nurse cares for a client who has diabetes mellitus. The nurse administers 6 units of regular insulin and 10 units of NPH insulin at 0700. At which time should the nurse assess the client for potential problems related to the NPH insulin? a. 0800 b. 1600 c. 2000 d. 2300
b. 1600
A nurse cares for a client with diabetes mellitus who asks, Why do I need to administer more than one injection of insulin each day? How should the nurse respond? a. You need to start with multiple injections until you become more proficient at self-injection. b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns. c. A regimen of a single dose of insulin injected each day would require that you eat fewer carbohydrates. d. A single dose of insulin would be too large to be absorbed, predictably putting you at risk for insulin shock.
b. A single dose of insulin each day would not match your blood insulin levels and your food intake patterns
A nurse is caring for a client who exhibits dehydration-induced confusion. Which intervention should the nurse implement first? a. Measure intake and output every 4 hours. b. Apply oxygen by mask or nasal cannula. c. Increase the IV flow rate to 250 mL/hr. d. Place the client in a high-Fowlers position.
b. Apply oxygen by mask or nasal cannula.
A nurse teaches a client with type 2 diabetes mellitus who is prescribed glipizide (Glucotrol). Which statement should the nurse include in this clients teaching? a. Change positions slowly when you get out of bed. b. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs). c. If you miss a dose of this drug, you can double the next dose. d. Discontinue the medication if you develop a urinary infection.
b. Avoid taking nonsteroidal anti-inflammatory drugs (NSAIDs)
A nurse on the medical-surgical unit has received a hand-off report. Which client should the nurse see first? a. Client being discharged later on a complicated analgesia regimen b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale c. Postoperative client who received oral opioid analgesia 45 minutes ago d. Client who has returned from physical therapy and is resting in the recliner
b. Client with new-onset abdominal pain, rated as an 8 on a 0-to-10 scale
The nurse in the surgery clinic is discussing an upcoming surgical procedure with a client. What information provided by the nurse is most appropriate for the clients long-term outcome? a. At least you know that the pain after surgery will diminish quickly. b. Discuss acceptable pain control after your operation with the surgeon. c. Opioids often cause nausea but you wont have to take them for long. d. The nursing staff will give you pain medication when you ask them for it
b. Discuss acceptable pain control after your operation with the surgeon.
A nurse teaches a client about self-monitoring of blood glucose levels. Which statement should the nurse include in this clients teaching to prevent bloodborne infections? a. Wash your hands after completing each test. b. Do not share your monitoring equipment. c. Blot excess blood from the strip with a cotton ball. d. Use gloves when monitoring your blood glucose.
b. Do not share your monitoring equipment.
A nurse is caring for a client on an epidural patient-controlled analgesia (PCA) pump. What action by the nurse is most important to ensure client safety? a. Assess and record vital signs every 2 hours. b. Have another nurse double-check the pump settings. c. Instruct the client to report any unrelieved pain. d. Monitor for numbness and tingling in the legs.
b. Have another nurse double-check the pump settings.
After teaching a client who is being treated for dehydration, a nurse assesses the clients understanding. Which statement indicates the client correctly understood the teaching? a. I must drink a quart of water or other liquid each day. b. I will weigh myself each morning before I eat or drink. c. I will use a salt substitute when making and eating my meals. d. I will not drink liquids after 6 PM so I wont have to get up at night.
b. I will weigh myself each morning before I eat or drink
A nurse cares for a client who is experiencing status epilepticus. Which prescribed medication should the nurse prepare to administer? a. Atenolol (Tenormin) b. Lorazepam (Ativan) c. Phenytoin (Dilantin) d. Lisinopril (Prinivil)
b. Lorazepam (Ativan)
A nurse teaches a client with diabetes mellitus about sick day management. Which statement should the nurse include in this clients teaching? a. When ill, avoid eating or drinking to reduce vomiting and diarrhea. b. Monitor your blood glucose levels at least every 4 hours while sick. c. If vomiting, do not use insulin or take your oral antidiabetic agent. d. Try to continue your prescribed exercise regimen even if you are sick.
b. Monitor your blood glucose levels at least every 4 hours while sick.
.A nurse assesses a client with diabetes mellitus. Which clinical manifestation should alert the nurse to decreased kidney function in this client? a. Urine specific gravity of 1.033 b. Presence of protein in the urine c. Elevated capillary blood glucose level d. Presence of ketone bodies in the urine
b. Presence of protein in the urine
A nurse obtains a health history on a client prior to administering prescribed sumatriptan succinate (Imitrex) for migraine headaches. Which condition should alert the nurse to hold the medication and contact the health care provider? a. Bronchial asthma b. Prinzmetals angina c. Diabetes mellitus d. Chronic kidney disease
b. Prinzmetals angina
After teaching a client with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I need to have an annual appointment even if my glucose levels are in good control. b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick. c. I can still develop complications even though I do not have to take insulin at this time. d. If I have surgery or get very ill, I may have to receive insulin injections for a short time.
b. Since my diabetes is controlled with diet and exercise, I must be seen only if I am sick.
A nurse is teaching a client who experiences migraine headaches and is prescribed a beta blocker. Which statement should the nurse include in this clients teaching? a. Take this drug only when you have prodromal symptoms indicating the onset of a migraine headache. b. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches. c. This drug will relieve the pain during the aura phase soon after a headache has started. d. This medication will have no effect on your heart rate or blood pressure because you are taking it for migraines.
b. Take this drug as ordered, even when feeling well, to prevent vascular changes associated with migraine headaches.
A nurse assesses a client with a history of epilepsy who experiences stiffening of the muscles of the arms , followed by an immediate loss of consciousness and jerking of all extremities. How should the nurse document this activity? a. Atonic seizure b. Tonic-clonic seizure c. Myoclonic seizure d. Absence seizure
b. Tonic-clonic seizure
A nurse is teaching a client with diabetes mellitus who asks, Why is it necessary to maintain my blood glucose levels no lower than about 60 mg/dL? How should the nurse respond? a. Glucose is the only fuel used by the body to produce the energy that it needs. b. Your brain needs a constant supply of glucose because it cannot store it. c. Without a minimum level of glucose, your body does not make red blood cells. d. Glucose in the blood prevents the formation of lactic acid and prevents acidosis.
b. Your brain needs a constant supply of glucose because it cannot store it.
A nurse teaches clients at a community center about risks for dehydration. Which client is at greatest risk for dehydration? a. A 36-year-old who is prescribed long-term steroid therapy b. A 55-year-old receiving hypertonic intravenous fluids c. A 76-year-old who is cognitively impaired d. An 83-year-old with congestive heart failure
c. A 76-year-old who is cognitively impaired
A nurse assesses a client with diabetes mellitus 3 hours after a surgical procedure and notes the clients breath has a fruity odor. Which action should the nurse take? a. Encourage the client to use an incentive spirometer. b. Increase the clients intravenous fluid flow rate. c. Consult the provider to test for ketoacidosis. d. Perform meticulous pulmonary hygiene care.
c. Consult the provider to test for ketoacidosis.
A nurse assesses a client who has a 15-year history of diabetes and notes decreased tactile sensation in both feet. Which action should the nurse take first? a. Document the finding in the clients chart. b. Assess tactile sensation in the clients hands. c. Examine the clients feet for signs of injury. d. Notify the health care provider.
c. Examine the clients feet for signs of injury.
A nurse is assessing pain on a confused older client who has difficulty with verbal expression. What pain assessment tool would the nurse choose for this assessment? a. Numeric rating scale b. Verbal Descriptor Scale c. FACES Pain Scale-Revised d. Wong-Baker FACES Pain Scale
c. FACES Pain Scale-Revised
.A nurse assesses a client who is being treated for hyperglycemic-hyperosmolar state (HHS). Which clinical manifestation indicates to the nurse that the therapy needs to be adjusted? a. Serum potassium level has increased. b. Blood osmolarity has decreased. c. Glasgow Coma Scale score is unchanged. d. Urine remains negative for ketone bodies.
c. Glasgow Coma Scale score is unchanged.
After teaching a client who is newly diagnosed with type 2 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching? a. I should increase my intake of vegetables with higher amounts of dietary fiber. b. My intake of saturated fats should be no more than 10% of my total calorie intake. c. I should decrease my intake of protein and eliminate carbohydrates from my diet. d. My intake of water is not restricted by my treatment plan or medication regimen.
c. I should decrease my intake of protein and eliminate carbohydrates from my diet.
A nurse is teaching a client with chronic migraine headaches. Which statement related to complementary therapy should the nurse include in this clients teaching? a. Place a warm compress on your forehead at the onset of the headache. b. Wear dark sunglasses when you are in brightly lit spaces. c. Lie down in a darkened room when you experience a headache. d. Set your alarm to ensure you do not sleep longer than 6 hours at one time.
c. Lie down in a darkened room when you experience a headache.
A student nurse asks why several clients are getting more than one type of pain medication instead of very high doses of one medication. What response by the registered nurse is best? a. A multimodal approach is the preferred method of control. b. Doctors are much more liberal with pain medications now. c. Pain is so complex it takes different approaches to control it. d. Clients are consumers and they demand lots of pain medicine.
c. Pain is so complex it takes different approaches to control it
A registered nurse (RN) and nursing student are caring for a client who is receiving pain medication via patient-controlled analgesia (PCA). What action by the student requires the RN to intervene? a. Assesses the clients pain level per agency policy b. Monitors the clients respiratory rate and sedation c. Presses the button when the client cannot reach it d. Reinforces client teaching about using the PCA pump
c. Presses the button when the client cannot reach it
A nurse assesses a client who has a history of migraines. Which clinical manifestation should the nurse identify as an early sign of a migraine with aura? a. Vertigo b. Lethargy c. Visual disturbances d. Numbness of the tongue
c. Visual disturbances
A nurse assesses clients who are at risk for diabetes mellitus. Which client is at greatest risk? a. A 29-year-old Caucasian b. A 32-year-old African- American c. A 44-year-old Asian d. A 48-year-old American Indian
d. A 48-year-old American Indian
.A nurse cares for a client experiencing diabetic ketoacidosis who presents with Kussmaul respirations. Which action should the nurse take? a. Administration of oxygen via face mask b. Intravenous administration of 10% glucose c. Implementation of seizure precautions d. Administration of intravenous insulin
d. Administration of intravenous insulin
A nurse on the postoperative inpatient unit receives a hand-off report on four clients using patient- controlled analgesia (PCA) pumps. Which client should the nurse see first? a. Client who appears to be sleeping soundly b. Client with no bolus request in 6 hours c. Client who is pressing the button every 10 minutes d. Client with a respiratory rate of 8 breaths/min
d. Client with a respiratory rate of 8 breaths/min
After teaching a young adult client who is newly diagnosed with type 1 diabetes mellitus, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the need for eye examinations? a. At my age, I should continue seeing the ophthalmologist as I usually do. b. I will see the eye doctor when I have a vision problem and yearly after age c. My vision will change quickly. I should see the ophthalmologist twice a year. d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.
d. Diabetes can cause blindness, so I should see the ophthalmologist yearly.
After teaching a client who is diagnosed with new-onset status epilepticus and prescribed phenytoin (Dilantin), the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching? a. To prevent complications, I will drink at least 2 liters of water daily. b. This medication will stop me from getting an aura before a seizure. c. I will not drive a motor vehicle while taking this medication. d. Even when my seizures stop, I will continue to take this drug.
d. Even when my seizures stop, I will continue to take this drug.
After teaching a client who has diabetes mellitus and proliferative retinopathy, nephropathy, and peripheral neuropathy, the nurse assesses the clients understanding. Which statement made by the client indicates a correct understanding of the teaching? a. I have so many complications; exercising is not recommended. b. I will exercise more frequently because I have so many complications. c. I used to run for exercise; I will start training for a marathon. d. I should look into swimming or water aerobics to get my exercise.
d. I should look into swimming or water aerobics to get my exercise.
After teaching a client newly diagnosed with epilepsy, the nurse assesses the clients understanding. Which statement by the client indicates a need for additional teaching? a. I will wear my medical alert bracelet at all times. b. While taking my epilepsy medications, I will not drink any alcoholic beverages. c. I will tell my doctor about my prescription and over-the-counter medications. d. If I am nauseated, I will not take my epilepsy medication.
d. If I am nauseated, I will not take my epilepsy medication.
A nurse assesses a client with diabetes mellitus who self-administers subcutaneous insulin. The nurse notes a spongy, swelling area at the site the client uses most frequently for insulin injection. Which action should the nurse take? a. Apply ice to the site to reduce inflammation. b. Consult the provider for a new administration route. c. Assess the client for other signs of cellulitis. d. Instruct the client to rotate sites for insulin injection.
d. Instruct the client to rotate sites for insulin injection
A nurse cares for a client who has type 1 diabetes mellitus. The client asks, Is it okay for me to have an occasional glass of wine? How should the nurse respond? a. Drinking any wine or alcohol will increase your insulin requirements. b. Because of poor kidney function, people with diabetes should avoid alcohol. c. You should not drink alcohol because it will make you hungry and overeat. d. One glass of wine is okay with a meal and is counted as two fat exchanges.
d. One glass of wine is okay with a meal and is counted as two fat exchanges.
A hospitalized client uses a transdermal fentanyl (Duragesic) patch for chronic pain. What action by the nurse is most important for client safety? a. Assess and record the clients pain every 4 hours. b. Ensure the client is eating a high-fiber diet. c. Monitor the clients bowel function every shift. d. Remove the old patch when applying the new one.
d. Remove the old patch when applying the new one.
An older client who lives alone is being discharged on opioid analgesics. What action by the nurse is most important? a. Discuss the need for home health care. b. Give the client follow-up information. c. Provide written discharge instructions. d. Request a home safety assessment.
d. Request a home safety assessment.
A client who had surgery has extreme postoperative pain that is worsened when trying to participate in physical therapy. What intervention for pain management does the nurse include in the clients care plan? a. As-needed pain medication after therapy b. Client-controlled analgesia with a basal rate c. Pain medications prior to therapy only d. Round-the-clock analgesia with PRN analgesics
d. Round-the-clock analgesia with PRN analgesics
A nurse reviews laboratory results for a client with diabetes mellitus who presents with polyuria, lethargy, and a blood glucose of 560 mg/dL. Which laboratory result should the nurse correlate with the clients polyuria? a. Serum sodium: 163 mEq/L b. Serum creatinine: 1.6 mg/dL c. Presence of urine ketone bodies d. Serum osmolarity: 375 mOsm/kg
d. Serum osmolarity: 375 mOsm/kg
A nurse is assessing pain in an older adult. What action by the nurse is best? a. Ask only yes-or-no questions so the client doesnt get too tired. b. Give the client a picture of the pain scale and come back later. c. Question the client about new pain only, not normal pain from aging. d. Sit down, ask one question at a time, and allow the client to answer.
d. Sit down, ask one question at a time, and allow the client to answer.
When teaching a client recently diagnosed with type 1 diabetes mellitus, the client states, I will never be able to stick myself with a needle. How should the nurse respond? a. I can give your injections to you while you are here in the hospital. b. Everyone gets used to giving themselves injections. It really does not hurt. c. Your disease will not be managed properly if you refuse to administer the shots. d. Tell me what it is about the injections that are concerning you.
d. Tell me what it is about the injections that are concerning you.
A nurse teaches a client with diabetes mellitus who is experiencing numbness and reduced sensation. Which statement should the nurse include in this clients teaching to prevent injury? a. Examine your feet using a mirror every day. b. Rotate your insulin injection sites every week. c. Check your blood glucose level before each meal. d. Use a bath thermometer to test the water temperature.
d. Use a bath thermometer to test the water temperature.
A nurse teaches a client with type 1 diabetes mellitus. Which statement should the nurse include in this clients teaching to decrease the clients insulin needs? a. Limit your fluid intake to 2 liters a day. b. Animal organ meat is high in insulin. c. Limit your carbohydrate intake to 80 grams a day. d. Walk at a moderate pace for 1 mile daily.
d. Walk at a moderate pace for 1 mile daily.
The nurse is assessing a clients pain and has elicited information on the location, quality, intensity, effect on functioning, aggravating and relieving factors, and onset and duration. What question by the nurse would be best to ask the client for completing a comprehensive pain assessment? a. Are you worried about addiction to pain pills? b. Do you attach any spiritual meaning to pain? c. How high would you say your pain tolerance is? d. What pain rating would be acceptable to you?
d. What pain rating would be acceptable to you?
A nurse reviews a female clients laboratory results. Which results from the clients urinalysis should the nurse recognize as abnormal? a. pH 5.6 b. Ketone bodies present c. Specific gravity of 1.020 d. Clear and yellow color
ketone bodies present
A nurse reviews a clients laboratory results. Which results from the clients urinalysis should the nurse identify as normal? (Select all that apply.) a. pH: 6 b. Specific gravity: 1.015 c. Protein: 1.2 mg/dL d. Glucose: negative e. Nitrate: small f. Leukocyte esterase: positive
pH: 6 Specific gravity: 1.015
A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) a. Sodium level b. Liver enzymes c. Clotting factors d. Cardiac enzymes e. Creatinine level
sodium level clotting factors