Med-S 1

The nurse is caring for a postoperative client who has just returned from the postanesthesia care unit after having nasal surgery. What priority action is essential for the nurse to perform? a. Assessing how often the client swallows b. Checking vital signs per agency protocol c. Viewing the external packing for bleeding d. Determining if the client can breathe through the unaffected nostril

a. Assessing how often the client swallows

A client who visits the health care provider's office for a routine physical examination reports new onset of intolerance to cold. Knowing that this is a frequent complaint associated with hypothyroidism, the nurse should check for which manifestations? a. Weight loss and thinning skin b. Complaints of weakness and lethargy c. Diaphoresis and increased hair growth d. Increased heart rate and respiratory rate

b. Complaints of weakness and lethargy

A client with diabetes mellitus demonstrates acute anxiety when admitted to the hospital for the treatment of hyperglycemia. What is the appropriate intervention to decrease the client's anxiety? a. Administer a sedative. b. Convey empathy, trust, and respect toward the client. c. Ignore the signs and symptoms of anxiety, anticipating that they will soon disappear. d. Make sure that the client is familiar with the correct medical terms to promote understanding of what is happening.

b. Convey empathy, trust, and respect toward the client.

The nurse is developing a plan of care for a client with varicose veins in whom skin breakdown occurred over the varicosities as a result of secondary infection. Which is a priority intervention? a. Keep the legs aligned with the heart. b. Elevate the legs higher than the heart. c. Clean the skin with alcohol every hour. d. Position the client onto the side during every shift.

b. Elevate the legs higher than the heart.

A client with diabetes mellitus is at risk for a serious metabolic disorder from the breakdown of fats for conversion to glucose. The nurse should anticipate that which substance will be elevated? a. Glucose b. Ketones c. Glucagon d. Lactate dehydrogenase

b. Ketones

A client is admitted to an emergency department, and a diagnosis of myxedema coma is made. Which action should the nurse prepare to carry out initially? a. Warm the client. b. Maintain a patent airway. c. Administer thyroid hormone. d. Administer fluid replacement.

b. Maintain a patent airway.

The nurse is monitoring a client with diabetes mellitus for signs of hypoglycemia. Which manifestations are associated with this complication? a. Slow pulse; lethargy; warm, dry skin b. Elevated pulse; lethargy; warm, dry skin c. Elevated pulse; shakiness; cool, clammy skin d. Slow pulse, confusion, increased urine output

c. Elevated pulse; shakiness; cool, clammy skin

The nurse performs a physical assessment on a client with type 2 diabetes mellitus. Findings include a fasting blood glucose level of 120 mg/dL (6.8 mmol/L), temperature of 101°F (38.3°C), pulse of 102 beats/minute, respirations of 22 breaths/minute, and blood pressure of 142/72 mm Hg. Which finding would be the priority concern to the nurse? a. Pulse b. Respiration c. Temperature d. Blood pressure

c. Temperature

The nurse is monitoring a client for signs of hypocalcemia after thyroidectomy. Which sign or symptom, if noted in the client, would most likely indicate the presence of hypocalcemia? a. Bradycardia b. Flaccid paralysis c. Tingling around the mouth d. Absence of Chvostek's sign

c. Tingling around the mouth

The nurse is caring for a client after thyroidectomy. The nurse notes that calcium gluconate is prescribed for the client. The nurse determines that this medication has been prescribed for which purpose? a. To treat thyroid storm b. To prevent cardiac irritability c. To treat hypocalcemic tetany d. To stimulate release of parathyroid hormone

c. To treat hypocalcemic tetany

A multidisciplinary health care team is developing a plan of care for a client with hyperparathyroidism. The nurse should include which priority intervention in the plan of care? a. Describe the use of loperamide. b. Restrict fluids to 1000 mL per day. c. Walk down the hall for 15 minutes 3 times a day. d. Describe the administration of aluminum hydroxide gel.

c. Walk down the hall for 15 minutes 3 times a day.

The nurse is performing an assessment on a client with a diagnosis of left-sided heart failure. Which assessment component would elicit specific information regarding the client's left-sided heart function? a. Listening to lung sounds b. Palpating for organomegaly c. Assessing for jugular vein distention d. Assessing for peripheral and sacral edema

a. Listening to lung sounds

A patient is diagnosed with an abdominal aortic aneurysm (AAA). Which of the patient's vital signs will be a priority for the healthcare provider to monitor? a. Core temperature b. Blood pressure c. Pulse rate d. Respiratory rate

b. Blood pressure

A client has been admitted with left-sided heart failure. When planning care for the client, interventions should be focused on reduction of which specific problem associated with this type of heart failure? a. Ascites b. Pedal edema c. Bilateral lung crackles d. Jugular vein distention

c. Bilateral lung crackles

The nurse's discharge teaching plan for the client with heart failure should emphasize the importance of doing which of the following? a. maintaining a high-fiber diet b. walking 2 miles (3.2 km) every day c. obtaining daily weights at the same time each day d. remaining sedentary for most of the day

c. obtaining daily weights at the same time each day

IV heparin therapy is ordered for a client. While implementing this order, the nurse ensures that which of the following medications is available on the unit? a. Vitamin K b. Aminocaproic acid c. Potassium chloride d. Protamine sulfate

d. Protamine sulfate

The nurse is discussing medications with a client with HTN who has a prescription for furosemide (Lasix) daily. The client needs further education whent the client states which of the following? a. "I know I should not drive after taking my Lasix." b. "I should be careful not to stand up too quickly when taking Lasix." c. "I should take the Lasix in the morning instead of before bed." d. "I need to be sure to also take the potassium supplement that th doctor prescribed along with my Lasix."

a. "I know I should not drive after taking my Lasix."

The client newly diagnosed with type 1 diabetes mellitus eats a lot of pasta products, such as macaroni and spaghetti and asks if they can be included in the diet. Which of the following would be the nurse's best response? a. "Pasta can be a part of your diet. It's included in the bread/starch exchange." b. "Pasta can be included in your diet but it shouldn't be served with sauces." c. "Eating pasta can cause hyperglycemia, so it's better to eliminate it." d. "Because you're overweight, it's better to eliminate pasta from your diet."

a. "Pasta can be a part of your diet. It's included in the bread/starch exchange."

The nurse is assessing a client's legs for the presence of edema. The nurse notes that the client has mild pitting with slight indentation and no perceptible swelling of the leg. How should the nurse define and document this finding? a. 1+ edema b. 2+ edema c. 3+ edema d. 4+ edema

a. 1+ edema

The nurse is assessing a client newly diagnosed with mild hypertension. Which assessment finding should the nurse expect? a. Asymptomatic b. Shortness of breath c. Visual disturbances d. Frequent nosebleeds

a. Asymptomatic

An adult with type 2 diabetes mellitus has been NPO since 10 pm in preparation for having a nephrectomy the next day. At 6 am on the day of surgery, the nurse reviews the client's chart and laboratory results. Which finding should the nurse report to the physician? a. Blood glucose of 160 mg/dL (7.8 mmol/L). b. Urine specific gravity of 1.015. c. Potassium of 4.0 mEq (4.0 mmol/L). d. Urine output of 350 mL in 8 hours.

a. Blood glucose of 160 mg/dL (7.8 mmol/L).

The nurse is performing a cardiovascular assessment on a client. Which parameter would the nurse assess to gain the best information about the client's left-sided heart function? a. Breath sounds b. Peripheral edema c. Hepatojugular reflux d. Jugular vein distention

a. Breath sounds

The nurse is planning care for a client with deep vein thrombosis of the right leg. Which interventions would the nurse plan, based on the health care provider's (HCP's) prescriptions? (Select all that apply.) a. Elevation of the right leg b. Administration of acetaminophen c. Application of moist heat to the right leg d. Monitoring for signs of pulmonary embolism e. Ambulation in around the nursing unit every hour

a. Elevation of the right leg b. Administration of acetaminophen c. Application of moist heat to the right leg d. Monitoring for signs of pulmonary embolism

The nurse is conducting a health history of a client with a primary diagnosis of heart failure. Which conditions reported by the client could play a role in exacerbating the heart failure? (Select all that apply.) a. Emotional stress b. Atrial fibrillation c. Nutritional anemia d. Peptic ulcer disease e. Recent upper respiratory infection

a. Emotional stress b. Atrial fibrillation c. Nutritional anemia e. Recent upper respiratory infection

The health care provider (HCP) prescribes limited activity (bed rest and bathroom only) for a client who developed deep vein thrombosis (DVT) after surgery. What interventions should the nurse plan to include in the client's plan of care? (Select all that apply.) a. Encourage coughing with deep breathing. b. Place in high Fowler's position for eating. c. Encourage increased oral intake of water daily. d. Place thigh-length elastic stockings on the client. e. Place sequential compression boots on the client. f. Encourage the intake of dark green, leafy vegetables.

a. Encourage coughing with deep breathing. c. Encourage increased oral intake of water daily. d. Place thigh-length elastic stockings on the client.

Mike, a 43-year old construction worker, has a history of hypertension. He smokes two packs of cigarettes a day, is nervous about the possibility of being unemployed, and has difficulty coping with stress. His current concern is calf pain during minimal exercise that decreased with rest. The nurse assesses Mike's symptoms as being associated with peripheral arterial occlusive disease. An appropriate nursing diagnosis is: a. Ineffective tissue perfusion related to compromised circulation. b. Dysfunctional use of extremities related to muscle spasms. c. Impaired mobility related to stress associated with pain. d. Impairment in muscle use associated with pain on exertion.

a. Ineffective tissue perfusion related to compromised circulation.

The nurse is developing a plan of care for a client who will be admitted to the hospital with a diagnosis of deep vein thrombosis (DVT) of the right leg. The nurse develops the plan, expecting that the health care provider (HCP) will most likely prescribe which option? a. Maintain activity level as prescribed. b. Maintain the affected leg in a dependent position. c. Administer an opioid analgesic every 4 hours around the clock. d. Apply cool packs to the affected leg for 20 minutes every 4 hours.

a. Maintain activity level as prescribed.

Which of these interventions should be the highest priority when caring for a patient with suspected abdominal aortic aneurysm (AAA) rupture? a. Maintaining blood pressure b. Obtaining a STAT electrocardiogram (EKG) c. Inserting an indwelling urinary catheter d. Increasing cardiac contractility

a. Maintaining blood pressure

The healthcare provider is reviewing risk factors for the development of an abdominal aortic aneurysm (AAA). Which of these inherited disorders in a patient's history is most likely related to the development of an AAA? a. Marfan syndrome b. Trisomy 21 c. Klinefelter syndrome d. Sickle cell anemia

a. Marfan syndrome

The nurse is reviewing laboratory results and notes that a client's serum sodium level is 150 mEq/L (150 mmol/L). The nurse reports the serum sodium level to the health care provider (HCP) and the HCP prescribes dietary instructions based on the sodium level. Which acceptable food items does the nurse instruct the client to consume? (Select all that apply.) a. Peas b. Nuts c. Cheese d. Cauliflower e. Processed oat cereals

a. Peas b. Nuts d. Cauliflower

While assessing the peripheral circulation of a patient with a diagnosis of an abdominal aortic aneurysm (AAA), the healthcare provider notes patchy mottling of the feet and toes. Pedal pulses are present. How should the healthcare provider interpret these findings? a. The patient's digital arteries have become occluded. b. The patient has a history of Raynaud Phenomenon. c. This is evidence of digital clubbing secondary to pulmonary disease. d. The patient's peripheral artery disease has progressed.

a. The patient's digital arteries have become occluded.

The nurse is admitting an older adult to the hospital. The echocardiogram report revealed left ventricular enlargement. The nurse notes 2+ pitting edema in the ankles when getting the client into bed. Based on this finding, what should the nurse do first? a. assess respiratory status b. draw blood for laboratory studies c. insert a Foley catheter d. weigh the client

a. assess respiratory status

The nurse is teaching a client with HTN about taking atenolol (Tenormin). The nurse should instruct the client to: a. avoid sudden discontinuation of the drug b. monitor the blood pressure annually c. follow a 2 g sodium diet d. discontinue the medicaton if severe headaches develop

a. avoid sudden discontinuation of the drug

An older adult with a history of heart failure is admitted to te emergency departnemtn with pulmonary edema. On asmission which of the following should the nurse assess first? a. blood pressure b. skin breakdown c. serum potassium level d. urine output

a. blood pressure

The nurse is assessing a client with chronic heart failure who is demonstrating neurohormonal compensatory mechanisms. Which of the following are expected findings on assessment? (Select all that apply) a. decreased cardiac output b. increased heart rate c. vasoconstriction in skin, GI tract, and kidneys d. decreased pulmonary perfusion e. fluid overload

a. decreased cardiac output b. increased heart rate c. vasoconstriction in skin, GI tract, and kidneys e. fluid overload

SMBG is being performed every 4 hours for a client diagnosed with diabetic ketoacidosis. Insulin is administered using a scale of regular insulin according to glucose results. At 2 p.m. (1400), the client has a capillary glucose level of 250 mg/dL for which he receives 8 units of regular insulin. The nurse should expect the dose's: a. onset to be at 2:30 p.m. (1430) and its peak to be at 4 p.m.(1600). b. onset to be at 4 p.m. (1600) and its peak to be at 6 p.m.(1800). c. onset to be at 2:15 p.m. (1415) and its peak to be at 3 p.m.(1500). d. onset to be at 2 p.m. (1400) and its peak to be at 3 p.m.(1500).

a. onset to be at 2:30 p.m. (1430) and its peak to be at 4 p.m.(1600).

A client diagnosed with primary (essential) HTN is taking chlorothiazide (Diuril). The nurse determines teaching about this medication is effective when the client makes the following statement. "I will... (Select all that apply.) a. take my weight daily at the same time each day." b. not drink alcoholic beverages while on this medicaton." c. reduce salt intake in my diet." d. reduce my dosage if I have severe dizziness." e. use sunscreen if I have prolonged exposure to sunlight." f. take the drug late in the evening."

a. take my weight daily at the same time each day." b. not drink alcoholic beverages while on this medicaton." c. reduce salt intake in my diet." e. use sunscreen if I have prolonged exposure to sunlight."

A client who has diabetes is taking metoprolol (Lopressor) for HTN. Which of the following information should the nurse include in the teaching plan? (Select all that apply) a. these tablets should be taken with food at the same time each day b. do not crush or chew tablets c. notify the health care provider if the pulse is 82 per minute d. have a blood glucose level drawn every 6 to 12 months during therapy e. use an appropriate decongestant if needed f. report any fainting spells to the health care provider

a. these tablets should be taken with food at the same time each day b. do not crush or chew tablets d. have a blood glucose level drawn every 6 to 12 months during therapy f. report any fainting spells to the health care provider

An agitated, confused client arrives in the ED. The client's history includes Type 1 diabetes, HTN, and angina pectoris. Assessment reveals pallor, diaphoresis, headache, and intense hunger. A stat blood glucose sample measures 42 mg/dL, (2.3 mmol/L) and the client is treated for an acute hypoglycemic reaction. After recovery, the nurse teaches the client to treat hypoglycemia by ingesting: a. 25 to 30 g of a simple carbohydrate. b. 15 g of a simple carbohydrate. c. 2 to 5 g of a simple carbohydrate. d. 18 to 20 g of a simple carbohydrate.

b. 15 g of a simple carbohydrate.

The healthcare provider is assessing a patient with a diagnosis of an abdominal aneurysm (AAA). Which of these assessment findings will the healthcare provider anticipate? a. A friction rub auscultated in the right upper abdominal quadrant b. A bruit auscultated over the periumbilical area c. Tenderness felt over the costovertebral angle (CVA) d. A venous hum auscultated in the epigastric area.

b. A bruit auscultated over the periumbilical area

The healthcare provider is assessing a patient who has a been diagnosed with an abdominal aortic aneurysm (AAA). Which assessment finding is an indication that the aneurysm is expanding? a. Hoarseness and cough b. A report of lower back pain c. Anginal pain d. Dysphasia

b. A report of lower back pain

Which information should the nurse include about hypoglycemia when teaching a client newly diagnosed with type 2 diabetes mellitus? (Select all that apply.) a. Hypoglycemia will not occur unless the client is taking insulin. b. Alcohol consumption can increase the incidence of hypoglycemia. c. A carbohydrate food source should be available during strenuous exercise. d. Regular meals and a bedtime snack will decrease the incidence of hypoglycemia. e. Symptoms of hypoglycemia can include irritability, hunger, shaking, and sweating.

b. Alcohol consumption can increase the incidence of hypoglycemia. c. A carbohydrate food source should be available during strenuous exercise. d. Regular meals and a bedtime snack will decrease the incidence of hypoglycemia. e. Symptoms of hypoglycemia can include irritability, hunger, shaking, and sweating.

The nurse is planning to teach a client with peripheral arterial disease about measures to limit disease progression. Which items should the nurse include on a list of suggestions for the client? (Select all that apply.) a. Soak the feet in hot water daily. b. Be careful not to injure the legs or feet. c. Use a heating pad on the legs to aid vasodilation. d. Walk each day to increase circulation to the legs. e. Cut down on the amount of fats consumed in the diet.

b. Be careful not to injure the legs or feet. d. Walk each day to increase circulation to the legs. e. Cut down on the amount of fats consumed in the diet.

With peripheral arterial insufficiency, leg pain during rest can be reduced by: a. Elevating the limb above heart level b. Lowering the limb so it is dependent c. Massaging the limb after application of cold compress d. Placing the limb in a plane horizontal to the body

b. Lowering the limb so it is dependent

The nurse provides instructions to a client with a low potassium level about the foods that are high in potassium and tells the client to consume which foods? (Select all that apply.) a. Peas b. Raisins c. Potatoes d. Cantaloupe e. Cauliflower f. Strawberries

b. Raisins c. Potatoes d. Cantaloupe f. Strawberries

After instruction on the application of antiembolism stockings, the nurse determines that the client requires further teaching if which of these actions is performed? a. The client puts on the stockings before getting out of bed. b. The client bunches up the stockings for easier application. c. The client ensures that stockings are pulled up all the way. d. The client ensures that the rough seams of the stockings are on the outside.

b. The client bunches up the stockings for easier application.

In teaching the client with HTN to avoid orthostatic hypotention, the nurse should emphasize which of the following instructions? (Select all that apply.) a. plan regular times for taking medications b. arise slowly from bed c. avoid standing still for long periods d. avoid excessive alcohol intake e. avoid hot baths

b. arise slowly from bed c. avoid standing still for long periods

A client receiving a loop diuretic should be encouraged to eat which of the following foods? (Select all that apply) a. angel food cake b. banana c. dried fruit d. orange juice e. peppers

b. banana c. dried fruit d. orange juice

An older adult with a history of HTN is admitted with diagnosis of dehydration. The client is becoming increasingly confused and weak. The client reports taking 1 tablet of HCTZ daily, and the prescription is written for 1/2 tablet. The nurse should obtain additional information about: a. decreased drug half-life on the HCTZ b. decreased hepatic blood flow c. icreased GI activity d. increased urinary elimination

b. decreased hepatic blood flow

Which of the following foods should the nurse teach a client with heart failure to limitwhen following a 2 g sodium diet? a. apples b. tomato juice c. whole wheat bread d. beef tenderloin

b. tomato juice

Which instruction about insulin administration should a nurse give to a client? a. "Discard the intermediate-acting (NPH) insulin if it appears cloudy." b. "Shake the vials before withdrawing the insulin." c. "Always follow the same order when drawing the different insulins into the syringe." d. "Store unopened vials of insulin in the freezer at temperatures well below freezing."

c. "Always follow the same order when drawing the different insulins into the syringe."

A diabetic patient has been prescribed an alpha-1 glucosidase inhibitor. When teaching the patient about the medication, which of the following information will the healthcare provider include? a. "Call us immediately if you experience tremors or palpitations." b. "Take one tablet daily first thing in the morning." c. "Take this medication with the first bite of each meal." d. "You should select foods low in protein when taking this medication."

c. "Take this medication with the first bite of each meal."

A home care nurse is visiting a client to provide follow-up evaluation and care of a leg ulcer. On removing the dressing from the leg ulcer, the nurse notes that the ulcer is pale and deep and that the surrounding tissue is cool to the touch. The nurse should document that these findings identify which type of ulcer? a. A stage 1 ulcer b. A vascular ulcer c. An arterial ulcer d. A venous stasis ulcer

c. An arterial ulcer

The nurse is providing instructions to a client with a diagnosis of hypertension regarding high-sodium items to be avoided. The nurse instructs the client to avoid consuming which item? a. Bananas b. Broccoli c. Antacids d. Cantaloupe

c. Antacids

The healthcare provider is teaching a group of students about the characteristics of type 1 diabetes mellitus. Which of the following describe the underlying cause of the disease? a. Increased hepatic glycogenesis b. Cellular resistance to insulin c. Destruction of pancreatic beta cells d. Atrophy of pancreatic alpha cells

c. Destruction of pancreatic beta cells

The client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan? a. Review the negative effects of smoking on the body. b. Discuss the effects of passive smoking on environmental pollution. c. Establish the client's daily smoking pattern. d. Explain how smoking worsens high blood pressure.

c. Establish the client's daily smoking pattern.

The nurse is caring for a client with heart failure who is receiving high doses of a diuretic. On assessment, the nurse notes that the client has flat neck veins, generalized muscle weakness, and diminished deep tendon reflexes. The nurse suspects hyponatremia. What additional signs would the nurse expect to note in a client with hyponatremia? a. Muscle twitches b. Decreased urinary output c. Hyperactive bowel sounds d. Increased specific gravity of the urine

c. Hyperactive bowel sounds

The nurse is auscultating a 56-year-old adult client's apical heart rate before giving digoxin and notes that the heart rate is 48 beats/minute. Which action should the nurse take? a. Withhold the digoxin, and re-evaluate the heart rate in 4 hours. b. Administer half of the prescribed dose to avoid a further decrease in heart rate. c. Withhold the digoxin, and assess for signs of decreased cardiac output and digoxin toxicity. d. Administer the digoxin; the heart rate would be considered normal because of the client's age.

c. Withhold the digoxin, and assess for signs of decreased cardiac output and digoxin toxicity.

A client with chronic heart failure has atrial fibrillation and a left ventricular ejection fraction of 15%. The client is taking warfarin (Coumadin). The expected outcome of this drug is to: a. decrease circulatory overload b. improve the myocardial workload c. prevent thrombus formation d. regulate cardiac rhythm

c. prevent thrombus formation

In which of the following psotions should the nurse place a client with heart failure who has orthopnea? a. semisitting (low Fowler's position) with legs elevated on pillows b. lying on the right side (Sims' position) with legs resting on the mattress c. sitting upright (high Fowler's position) with legs resting on the mattress d. lying on the back with head lowered (Trendelenburg's position) and legs elevated

c. sitting upright (high Fowler's position) with legs resting on the mattress

The home care nurse is providing instructions to a client with an arterial ischemic leg ulcer about home care management and self-care management. Which statement, if made by the client, indicates a need for further instruction? a. "I need to be sure not to go barefoot around the house." b. "If I cut my toenails, I need to be sure that I cut them straight across." c. "It is all right to apply lanolin to my feet, but I shouldn't place it between my toes." d. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

d. "I need to be sure that I elevate my leg above the level of my heart for at least an hour every day."

A client is admitted to the visiting nurse service for assessment and follow-up after being discharged from the hospital with new-onset heart failure (HF). The nurse teaches the client about the dietary restrictions required with HF. Which statement by the client indicates that further teaching is needed? a. "I'm not supposed to eat cold cuts." b. "I can have most fresh fruits and vegetables." c. "I'm going to weigh myself daily to be sure I don't gain too much fluid." d. "I'm going to have a ham and cheese sandwich and potato chips for lunch."

d. "I'm going to have a ham and cheese sandwich and potato chips for lunch."

The healthcare provider is evaluating effectiveness of discharge teaching for a male patient following an abdominal aortic aneurysm (AAA) repair. Which of these statements made by the patient indicates the teaching has been successful? a. "I will take my radial pulse each day and keep track of the rate." b. "I should avoid being around people who are sick." c. "I'll be able to resume my usual work-out at the gym." d. "It's possible that I may experience some sexual dysfunction."

d. "It's possible that I may experience some sexual dysfunction."

Which instruction should a nurse give to a client with DM when teaching about "sick day rules"? a. "Don't take your insulin or oral antidiabetic agent if you don't eat." b. "It's okay for your blood glucose to go above 300 mg/dL while you're sick." c. "Follow your regular meal plan, even if you're nauseous." d. "Test your blood glucose every 4 hours."

d. "Test your blood glucose every 4 hours."

On a medical-surgical floor, a nurse is caring for a cluster of clients with diabetes mellitus. Which client should the nurse assess first? a. A 60-year-old client experiencing nausea and vomiting b. A 20-year-old client with a blood glucose level of 70 mg/dl c. An 80-year-old client with a blood glucose level of 350 mg/dl d. A 55-year-old complaining of chest pain

d. A 55-year-old complaining of chest pain

A diabetic patient has the following presentation: unresponsive to voice or touch, tachycardia, diaphoresis, and pallor. Which of the following actions by the healthcare provider is the priority? a. Send blood to the laboratory for analysis b. Administer the prescribed insulin c. Administer oxygen per nasal cannula d. Administer 50% dextrose IV per protocol

d. Administer 50% dextrose IV per protocol

During an assessment of a patient's abdomen, a pulsating abdominal mass is noted by the healthcare provider. Which of the following should be the healthcare provider's next action? a. Ask the patient to perform a Valsalva maneuver b. Obtain a bladder scan c. Measure the abdominal circumference d. Assess femoral pulses

d. Assess femoral pulses

Which is the priority assessment in the care of a client who is newly admitted to the hospital for acute arterial insufficiency of the left leg and moderate chronic arterial insufficiency of the right leg? a. Monitor oxygen saturation with pulse oximetry. b. Assess activity tolerance before and after exercise. c. Observe the client's cardiac rhythm with telemetry. d. Assess peripheral pulses with an ultrasonic Doppler device.

d. Assess peripheral pulses with an ultrasonic Doppler device.

The nurse is performing a health screening on a 54-year-old client. The client has a blood pressure of 118/78 mm Hg, total cholesterol level of 190 mg/dL (4.9 mmol/L), and fasting blood glucose level of 184 mg/dL (10.2 mmol/L). The nurse interprets this to mean that the client has which modifiable risk factor for coronary artery disease (CAD)? a. Age b. Hypertension c. Hyperlipidemia d. Glucose intolerance

d. Glucose intolerance

An unresponsive patient who has diabetes is brought to the emergency department with slow, deep respirations. Additional findings include: blood glucose 450 mg/dL (24.9 mmol/L), arterial pH 7.2, and urinalysis showing presence of ketones and glucose. a. Hyperglycemia causes oxidative stress, renal dysfunction, and acidosis b. Hypoglycemia causes release of glucagon resulting in glycogenolysis and hyperglycemia c. Nocturnal elevation of growth hormone results in hyperglycemia in the morning d. Lack of insulin causes increased counterregulatory hormones and fatty acid release

d. Lack of insulin causes increased counterregulatory hormones and fatty acid release

The nurse is performing an admission assessment on a client with a diagnosis of Raynaud's disease. How should the nurse assess for this disease? a. Checking for a rash on the digits b. Observing for softening of the nails or nail beds c. Palpating for a rapid or irregular peripheral pulse d. Palpating for diminished or absent peripheral pulses

d. Palpating for diminished or absent peripheral pulses

While reviewing the day's charts, a nurse who's been under a great deal of personal stress realizes that she forgot to administer insulin to client with diabetes mellitus. She's made numerous errors in the past few weeks and is now afraid her job is in jeopardy. What is her best course of action? a. Contact the physician and follow his instructions. b. Report the error and request a private meeting with the unit manager. c. Administer the medication immediately and chart it as given on time. d. Report the error, complete the proper paperwork, and meet with the unit manager.

d. Report the error, complete the proper paperwork, and meet with the unit manager.

A patient diagnosed with type 2 diabetes mellitus is admitted to the medical unit with pneumonia. The patient's oral antidiabetic medication has been discontinued and the patient is now receiving insulin for glucose control. Which of the following statements best explains the rationale for this change in medication? a. Acute illnesses like pneumonia will cause increased insulin resistance. b. Infection has compromised beta cell function so the patient will need insulin from now on. c. Insulin administration will help prevent hypoglycemia during the illness. d. Stress-related states such as infections increase risk of hyperglycemia.

d. Stress-related states such as infections increase risk of hyperglycemia

Which of the following sets of conditions is an indication that a client with a history of left-sided heart failure is developing pulmonary edema? (Select all that apply.) a. distended jugular veins b. dependent edema c. anorexia d. coarse crackles e. tachycardia

d. coarse crackles e. tachycardia

Lasix (furosemide) 40 mg IVP is prescribed. Lasix 10 mg/mL is available. The nurse should administer __________ mL.

4 mL

What are the 6 P's of a neurovascular assessment?

Pain Pallor (color) Pulselessness Polar (temperature) Paresthesia (loss of sensation) Paralysis

The nurse is teaching a client with hyperparathyroidism how to manage the condition at home. Which response by the client indicates the need for additional teaching? a. "I should limit my fluids to 1 liter per day." b. "I should use my treadmill or go for walks daily." c. "I should follow a moderate-calcium, high-fiber diet." d. "My alendronate helps to keep calcium from coming out of my bones."

a. "I should limit my fluids to 1 liter per day."

During physical examination of a client, which finding is characteristic of hypothyroidism? a. Periorbital edema b. Flushed, warm skin c. Hyperactive bowel sounds d. Heart rate of 120 beats/min

a. Periorbital edema

A client with suspected primary hyperparathyroidism is undergoing diagnostic testing. The nurse would assess for which as a manifestation of this disorder? a. Polyuria b. Diarrhea c. Polyphagia d. Weight gain

a. Polyuria

A client has overactivity of the thyroid gland. The nurse should expect which finding? a. Weight gain b. Nutritional deficiencies c. Low blood glucose levels d. Increased body fat stores

b. Nutritional deficiencies

When a client is transferred from the postanesthesia care unit and arrives on the surgical unit, which should be the first action taken by the nurse? a. Assess the client's pain. b. Obtain the client's vital signs. c. Administer oxygen to the client. d. Check the rate of the intravenous infusion.

b. Obtain the client's vital signs.

A client with type 1 diabetes mellitus is admitted to the emergency department with suspected diabetic ketoacidosis (DKA). Which laboratory result would be expected with this diagnosis? a. Urine is negative for ketones. b. Serum potassium is 6.8 mEq/L (6.8 mmol/L). c. Serum osmolality is 260 mOsm/kg (260 mmol/kg) H20. d. Arterial blood gas values are pH 7.52, PCO2 44 mm Hg, HCO3- 30 mEq/L (30 mmol/L).

b. Serum potassium is 6.8 mEq/L (6.8 mmol/L).

The nurse teaches a client with diabetes mellitus about differentiating between hypoglycemia and ketoacidosis. The client demonstrates an understanding of the teaching by stating that a form of glucose should be taken if which symptom or symptoms develop? (Select all that apply.) a. Polyuria b. Shakiness c. Palpitations d. Blurred vision e. Lightheadedness f. Fruity breath odor

b. Shakiness c. Palpitations e. Lightheadedness

A postoperative client with a large abdominal wound requiring frequent dressing changes is starting to develop skin irritation in the area where the dressing tape is applied to the skin. The nurse determines that the client would benefit most from which measure? a. Obtaining a wound culture b. The use of Montgomery straps c. The use of hypoallergenic tape d. Cleansing the irritated area with povidone-iodine

b. The use of Montgomery straps

A client with heart failure is receiving digoxin intravenously. The nurse should determine the effectiveness of the drug by assessing which of the following? a. dilated coronary arteries b. increased myocardial contractility c. decreased cardiac arrhythmias d. decreased electrical conductivity in the heart

b. increased myocardial contractility

When assessing an older adult, the nurse finds the apical impulse below the fifth intercostal space. The nurse should further assess the client for: a. left atrial enlargement b. left ventricular enlargement c. right atrial enlargement d. right ventricular elargement

b. left ventricular enlargement

When caring for a patient who has started anticoagulant therapy with warfarin (Coumadin), the nurse knows not to expect therapeutic benefits for: a. at least 12 hours b. the first 24 hours c. 3-5 days d. 1 week

c. 3-5 days

The nurse is teaching a graduate nurse in the operating room about the components of Universal Protocol, one of The Joint Commission's National Patient Safety Goals. What specific component should the nurse include in the instructions? a. Surgical site should be marked preoperatively. b. Surgical sponges should be counted at the end of the surgery. c. A time-out should be performed in the operating room before the procedure. d. Preoperative antibiotic should be administered within 1 hour of the incision.

c. A time-out should be performed in the operating room before the procedure.

The nurse is assessing a client who had abdominal surgery earlier in the day. Which preexisting medical condition would place the client at most risk for postoperative complications? a. Pacemaker b. Osteoporosis c. Alcohol abuse d. Peptic ulcer disease

c. Alcohol abuse

The nurse is providing home care instructions to the parents of an infant who had a surgical repair of an inguinal hernia. What instruction should the nurse include to prevent infection at the surgical site? a. Report a fever immediately. b. Restrict the infant's physical activity. c. Change the diapers as soon as they become damp. d. Soak the infant in a tub bath twice a day for the next 5 days.

c. Change the diapers as soon as they become damp.

The nurse is performing an assessment on a client admitted to the hospital with a diagnosis of dehydration. Which assessment finding should the nurse expect to note? a. Bradycardia b. Elevated blood pressure c. Changes in mental status d. Bilateral crackles in the lungs

c. Changes in mental status

A hospitalized client is experiencing an episode of hypoglycemia. The client is lethargic and has no available intravenous (IV) access. Which medication should the nurse anticipate administering? a. Insulin b. Cortisone c. Glucagon d. Epinephrine

c. Glucagon

A client's serum blood glucose level is 389 mg/dL (22.2 mmol/L). The nurse would expect to note which as an additional finding when assessing this client? a. Unsteady gait b. Slurred speech c. Increased thirst d. Cold, clammy skin

c. Increased thirst

The nurse is providing instructions regarding insulin administration for a client newly diagnosed with diabetes mellitus. The health care provider has prescribed a mixture of NPH insulin and regular insulin. The nurse should instruct the client that which is the first step in this procedure? a. Draw up the correct dosage of NPH insulin into the syringe. b. Draw up the correct dosage of regular insulin into the syringe. c. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin. d. Inject air equal to the amount of regular insulin prescribed into the vial of regular insulin.

c. Inject air equal to the amount of NPH insulin prescribed into the vial of NPH insulin.

The nurse is preparing discharge instructions for a client with Raynaud's disease. The nurse should plan to provide which instruction to the client? a. Use nail polish to protect the nail beds from injury. b. Wear gloves for all activities involving the use of both hands. c. Stop smoking because it causes cutaneous blood vessel spasm. d. Always wear warm clothing, even in warm climates, to prevent vasoconstriction.

c. Stop smoking because it causes cutaneous blood vessel spasm.

The nurse should teach the client that signs of digoxin toxicity include which of the following? a. rash over the chest and back b. increased appetite c. visual disturbances such as seeing yellow spots d. elevated blood pressure

c. visual disturbances such as seeing yellow spots

A client with diabetes mellitus has been instructed in the dietary exchange system. The client asks the nurse if bacon is allowed in the diet. Which nursing response is most appropriate? a. "Bacon is not allowed." b. "Bacon is much too high in fat." c. "Bacon may be eaten if you eliminate 1 meat item from your diet." d. "One strip of bacon may be eaten if you eliminate 1 teaspoon of butter."

d. "One strip of bacon may be eaten if you eliminate 1 teaspoon of butter."

The healthcare provider administers NPH insulin to a patient who has diabetes at 6:00 AM. When will the patient be at highest risk of experiencing hypoglycemia? a. 7:00 AM b. 7:30 AM c. 9:00 AM d. 10:00 AM

d. 10:00 AM

The nurse is reviewing the health care provider's (HCP's) prescriptions for a client with a diagnosis of diabetes mellitus who has been hospitalized for treatment of an infected foot ulcer. The nurse expects to note which finding in the HCP's prescriptions? a. A decreased-calorie diet b. An increased-calorie diet c. A decreased amount of NPH insulin daily insulin d. An increased amount of NPH insulin daily insulin

d. An increased amount of NPH insulin daily insulin

A young man with type 1 diabetes mellitus tells the nurse that he might lose his job because he has been having frequent hypoglycemic reactions. His boss thinks that he is drunk during these episodes and that he has been drinking on the job. Which action by the nurse would best assist this client to meet his needs? a. Ask the client if he indeed has been drinking at work. b. Ask the client what he does to treat his hypoglycemia. c. Contact the local employment office to help him find another job. d. Examine factors with the client that may be causing frequent hypoglycemic episodes.

d. Examine factors with the client that may be causing frequent hypoglycemic episodes.

A client who has undergone radical neck dissection is experiencing problems with verbal communication related to postoperative hoarseness. The nurse should formulate which outcome as the most appropriate goal for this client problem? a. Uses nonverbal communication only b. Describes that hoarseness will be permanent c. Initiates communication only when necessary d. Incorporates nonverbal forms of communication as needed

d. Incorporates nonverbal forms of communication as needed

Which of the following laboratory results would alert the healthcare provider that a patient who has diabetes is experiencing diabetic nephropathy? a. Hemoglobin A1c 6% b. Decreased BUN c. Ketonuria d. Microalbuminuria

d. Microalbuminuria

A client arrives at the surgical unit after undergoing rhinoplasty and has a nose splint and gauze drip (moustache dressing) in place. The nurse reviews the health care provider's prescriptions and anticipates that which client position will be prescribed? a. Sims' b. Prone c. Supine d. Semi Fowler's

d. Semi Fowler's

Which intervention would be most likely to assist the client with HTN in maintaining an exercise program? a. giving the client a written exercise program b. explaining the exercise program to the client's spouse c. reassurig the client that he or she can do the exercise program d. tailoring a program to the client's needs and abilities

d. tailoring a program to the client's needs and abilities

A 33-year-old female client is admitted to the hospital with a tentative diagnosis of Graves' disease. Which symptom related to the menstrual cycle would the client be most likely to report during the initial assessment? a. Amenorrhea b. Menorrhagia c. Metrorrhagia d. Dysmenorrhea

a. Amenorrhea

In preparation for ambulation, the nurse is planning to assist a postoperative client to progress from a lying position to a sitting position. Which nursing action is appropriate to maintain the safety of the client? a. Assess the client for signs of dizziness and hypotension. b. Allow the client to rise from the bed to a standing position unassisted. c. Elevate the head of the bed quickly to assist the client to a sitting position. d. Assist the client to move quickly from the lying position to the sitting position.

a. Assess the client for signs of dizziness and hypotension.

The nurse receives a telephone call from the postanesthesia care unit stating that a client is being transferred to the surgical unit. The nurse plans to take which action first on arrival of the client? a. Assess the patency of the airway. b. Check tubes or drains for patency. c. Check the dressing to assess for bleeding. d. Assess the vital signs to compare with preoperative measurements.

a. Assess the patency of the airway.

The nurse is caring for a client with heart failure (HF). Which signs and symptoms could indicate fluid overload? (Select all that apply.) a. Bounding pulse b. Difficulty breathing c. Increased urine output d. Presence of dependent edema e. Neck vein distention in the upright position

a. Bounding pulse b. Difficulty breathing d. Presence of dependent edema e. Neck vein distention in the upright position

The nurse is caring for a client who is postoperative following a pelvic exenteration and the health care provider changes the client's diet from NPO (nothing by mouth) status to clear liquids. The nurse should check which priority item before administering the diet? a. Bowel sounds b. Ability to ambulate c. Incision appearance d. Urine specific gravity

a. Bowel sounds

A client is admitted to a surgical unit postoperatively with a wound drain in place. Which actions should the nurse take in the care of the drain? (Select all that apply.) a. Check the drain for patency. b. Observe for bright red bloody drainage. c. Clamp the drain for 15 minutes every hour. d. Curl the drain tightly, and tape it firmly to the body. e. Maintain aseptic technique when emptying the drain.

a. Check the drain for patency. b. Observe for bright red bloody drainage. e. Maintain aseptic technique when emptying the drain.

A client has a risk for infection following radical vulvectomy. Therefore, the nurse should avoid which action when giving perineal care to this client? a. Cleansing with warm tap water b. Intermittently exposing the wound to air c. Providing prescribed sitz baths after the sutures are removed d. Providing perineal care after each voiding and bowel movement

a. Cleansing with warm tap water

The nurse is caring for a client with a diagnosis of severe dehydration. The client has been receiving intravenous (IV) fluids and nasogastric (NG) tube feedings. The nurse monitors fluid balance using which as the best indicator? a. Daily weight b. Urinary output c. IV fluid intake d. NG tube intake

a. Daily weight

A client scheduled for surgery receives a dose of scopolamine. The nurse expects to note which side effects of the medication? (Select all that apply.) a. Dry mouth b. Diaphoresis c. Profuse diarrhea d. Pupillary dilation e. Excessive urination

a. Dry mouth d. Pupillary dilation

The nurse is performing an assessment on a client with a diagnosis of myxedema (hypothyroidism). Which assessment finding should the nurse expect to note in this client? a. Dry skin b. Thin, silky hair c. Bulging eyeballs d. Fine muscle tremors

a. Dry skin

The nurse is providing dietary instructions to help with diabetes control for a client newly diagnosed with diabetes mellitus who will be taking insulin. The nurse should provide the client with which best instruction? a. Eat meals at approximately the same time each day. b. Adjust mealtimes depending on blood glucose levels. c. Vary mealtimes if insulin is not administered at the same time every day. d. Avoid being concerned about the time of meals as long as snacks are taken on time.

a. Eat meals at approximately the same time each day.

The nurse is creating a plan of care for a client with hypokalemia. Which interventions should be included in the plan of care? (Select all that apply.) a. Ensure adequate fluid intake. b. Implement safety measures to prevent falls. c. Encourage low-fiber foods to prevent diarrhea. d. Instruct the client about foods that contain potassium. e. Encourage the client to obtain assistance to ambulate.

a. Ensure adequate fluid intake. b. Implement safety measures to prevent falls. d. Instruct the client about foods that contain potassium. e. Encourage the client to obtain assistance to ambulate.

A client arrives in the hospital emergency department in an unconscious state. As reported by the spouse, the client has diabetes mellitus and began to show symptoms of hypoglycemia. A blood glucose level is obtained for the client, and the result is 40 mg/dL (2.28 mmol/L). Which medication should the nurse anticipate will be prescribed for the client? a. Glucagon b. Glyburide c. Metformin d. Regular insulin

a. Glucagon

A client who has undergone preadmission testing has had blood drawn for serum laboratory studies, including a complete blood count, coagulation studies, and electrolytes and creatinine levels. Which laboratory result should be reported to the surgeon's office by the nurse, knowing that it could cause surgery to be postponed? a. Hemoglobin, 8.0 g/dL (80 mmol/L) b. Sodium, 145 mEq/L (145 mmol/L) c. Serum creatinine, 0.8 mg/dL (70.6 mmol/L) d. Platelets, 210,000 mm3 (210 × 109/L)

a. Hemoglobin, 8.0 g/dL (80 mmol/L)

The nurse is monitoring the status of a postoperative client in the immediate postoperative period. The nurse would become most concerned with which sign that could indicate an evolving complication? a. Increasing restlessness b. A pulse of 86 beats/minute c. Blood pressure of 110/70 mm Hg d. Hypoactive bowel sounds in all 4 quadrants

a. Increasing restlessness

A client has abnormal amounts of circulating thyronine (T3) and thyroxine (T4). While obtaining the health history, the nurse asks the client about dietary intake. Lack of which dietary element is most likely the cause? a. Iodine b. Calcium c. Phosphorus d. Magnesium

a. Iodine

A client with Graves' disease has exophthalmos and is experiencing photophobia. Which nursing action would best assist the client with these manifestations? a. Obtain dark glasses for the client. b. Lubricate the eyes with tap water every 2 to 4 hours. c. Administer methimazole every 8 hours around the clock. d. Instruct the client to avoid straining or heavy lifting because this effort can increase eye pressure.

a. Obtain dark glasses for the client.

An unconscious patient arrives at the emergency department. Periumbilical (Cullen's sign) and flank ecchymosis (Grey Turner's sign) is noted , and a ruptured abdominal aortic aneurysm (AAA) is suspected. Which of these additional assessment findings will the healthcare provider anticipate? a. Pale, clammy skin b. Expiratory wheezes c. Decorticate posturing d. Pinpoint pupils

a. Pale, clammy skin

While recovering from an endovascular aortic repair (EVAR) of an abdominal aortic aneurysm (AAA), the patient experiences numbness and tingling in the feet. What is the healthcare provider's priority action? a. Palpate the pedal pulses b. Gently massage the legs and feet c. Assist the patient to ambulate d. Apply warm compresses to the feet

a. Palpate the pedal pulses

The nurse is reviewing a client's laboratory report and notes that the total serum calcium level is 6.0 mg/dL (1.66 mmol/L). The nurse understands that which condition most likely caused this serum calcium level? a. Prolonged bed rest b. Renal insufficiency c. Hyperparathyroidism d. Excessive ingestion of vitamin D

a. Prolonged bed rest

The nurse is providing discharge instructions to the client who has had a pneumonectomy and prepares a list of postoperative instructions for the client. Which intervention should the nurse include in the list? a. Report any signs of respiratory infection to the health care provider. b. Avoid breathing exercises to allow the diaphragm to strengthen. c. Avoid lifting any objects greater than 30 pounds for at least 3 weeks. d. Contact the health care provider if any feelings of weakness and fatigue occur.

a. Report any signs of respiratory infection to the health care provider.

A nurse notes that a client with type 1 diabetes mellitus has lipodystrophy on both upper thighs. The nurse should ask the client if which measure is taken? a. Rotating sites for injection b. Administering the insulin at a 45-degree angle c. Cleaning the skin with alcohol before each injection d. Aspirating for blood before injection into the subcutaneous tissue

a. Rotating sites for injection

A client's serum blood glucose level is 48 mg/dL (2.74 mmol/L). The nurse would expect to note which as an additional finding when assessing this client? a. Slurred speech b. Increased thirst c. Increased appetite d. Increased urination

a. Slurred speech

A client has had an invasive abdominal surgery to relieve an obstruction of the common bile duct. The client's surgery is completed, and the client has been transferred to the postanesthesia care unit (PACU). The PACU nurse observes that the client suddenly appears red in the face and appears to be coughing despite the presence of an endotracheal tube and ventilator support. What action should the PACU nurse take first? a. Suction the client through the endotracheal tube. b. Instruct the client in the use of an incentive spirometer. c. Turn the client from a 30-degree lateral position to a supine position. d. Instruct the client to use a communication board to tell the nurse what is wrong.

a. Suction the client through the endotracheal tube.

The nurse is assessing the colostomy of a client who has had an abdominal perineal resection for a bowel tumor. Which assessment finding indicates that the colostomy is beginning to function? a. The passage of flatus b. Absent bowel sounds c. The client's ability to tolerate food d. Bloody drainage from the colostomy

a. The passage of flatus

A client with diabetes mellitus develops sinusitis and otitis media accompanied by a temperature of 100.8° F (38.2° C). What effect do these findings have on his need for insulin? a. They increase the need for insulin. b. They decrease the need for insulin. c. They have no effect. d. They cause wide fluctuations in the need for insulin.

a. They increase the need for insulin.

A client with an endocrine disorder has experienced recent weight loss and exhibits tachycardia. Based on the clinical manifestations, the nurse should suspect dysfunction of which endocrine gland? a. Thyroid b. Pituitary c. Parathyroid d. Adrenal cortex

a. Thyroid

A nurse is assigned to care for a client with type 1 diabetes mellitus. During the shift, the nurse should monitor for which manifestation as a sign of hypoglycemia? a. Tremors b. Anorexia c. Hot, dry skin d. Muscle cramps

a. Tremors

The nurse is monitoring a client who was diagnosed with type 1 diabetes mellitus and is being treated with NPH and regular insulin. Which manifestations would alert the nurse to the presence of a possible hypoglycemic reaction? (Select all that apply.) a. Tremors b. Anorexia c. Irritability d. Nervousness e. Hot, dry skin f. Muscle cramps

a. Tremors c. Irritability d. Nervousness

The nurse is assessing a client with a suspected diagnosis of hypocalcemia. Which clinical manifestation would the nurse expect to note in the client? a. Twitching b. Hypoactive bowel sounds c. Negative Trousseau's sign d. Hypoactive deep tendon reflexes

a. Twitching

A client recovering from pulmonary edema is preparing for discharge. What should the nurse plan to teach the client to do to manage or prevent recurrent symptoms after discharge? a. Weigh self on a daily basis. b. Sleep with the head of the bed flat. c. Take a double dose of the diuretic if peripheral edema is noted. d. Withhold prescribed digoxin if slight respiratory distress occurs.

a. Weigh self on a daily basis.

The nurse caring for a client who has been receiving intravenous (IV) diuretics suspects that the client is experiencing a fluid volume deficit. Which assessment finding would the nurse note in a client with this condition? a. Weight loss and poor skin turgor b. Lung congestion and increased heart rate c. Decreased hematocrit and increased urine output d. Increased respirations and increased blood pressure

a. Weight loss and poor skin turgor

The nurse is developing a list of home care instructions for a client being discharged after a laparoscopic cholecystectomy. Which instructions should the nurse include in the postoperative discharge plan of care? (Select all that apply.) a. Wound care b. Follow-up care c. Activity restrictions d. Dietary instructions e. Deep-breathing exercises

a. Wound care b. Follow-up care c. Activity restrictions d. Dietary instructions

The nurse should assess the client with left-sided heart failure for which of the following? (Select all) a. dyspnea b. JVD c. crackles d. right upper quadrant pain e. oliguria f. decreased oxygen saturation levels

a. dyspnea c. crackles e. oliguria f. decreased oxygen saturation levels

The major goal of nursing care for a client with heart failure and pulmonary edema is to: a. increase cardiac output b. improve respiratory status c. decrease peripheral edema d. enhance comfort

a. increase cardiac output

The healthcare provider is caring for a patient who has diabetes and is also diagnosed with hypertension. Which of the following medications on the patient's medication administration record will cause the most concern? a. Calcium channel blocker b. Beta-blocker c. Angiotensin receptor blocker d. ACE inhibitor

b. Beta-blocker

The nurse is performing an assessment on a client with a diagnosis of hyperthyroidism. Which assessment finding should the nurse expect to note in this client? a. Dry skin b. Bulging eyeballs c. Periorbital edema d. Coarse facial features

b. Bulging eyeballs

The nurse is caring for a client with a severe burn who is scheduled for an autograft to be placed on the lower extremity. The nurse creates a postoperative plan of care for the client and should include which intervention in the plan? a. Maintain the client in a prone position. b. Elevate and immobilize the grafted extremity. c. Maintain the grafted extremity in a flat position. d. Keep the grafted extremity covered with a blanket.

b. Elevate and immobilize the grafted extremity.

The healthcare provider is assessing the glucose level of a patient with a diagnosis of diabetes. Which of these is most helpful in evaluating this patient's long-term glucose management? a. Fasting blood glucose level b. Hemoglobin A1c c. Urine specific gravity d. The patient's food diary

b. Hemoglobin A1c

The clinic nurse is providing instructions to a client with diabetes mellitus about the signs and symptoms of hypoglycemia. The nurse should tell the client that which would be noted in a hypoglycemic reaction? a. Thirst b. Hunger c. Polydipsia d. Increased urine output

b. Hunger

The nurse is preparing a plan of care for a client with diabetes mellitus who has hyperglycemia. The nurse places priority on which client problem? a. Lack of knowledge b. Inadequate fluid volume c. Compromised family coping d. Inadequate consumption of nutrients

b. Inadequate fluid volume

A client complains of calf tenderness, and thrombophlebitis is suspected. The nurse should next assess the client for which finding? a. Bilateral edema b. Increased calf circumference c. Diminished distal peripheral pulses d. Coolness and pallor of the affected limb

b. Increased calf circumference

The nurse is providing instructions to a client newly diagnosed with diabetes mellitus. The nurse gives the client a list of the signs of hyperglycemia. Which specific sign of this complication should be included on the list? a. Shakiness b. Increased thirst c. Profuse sweating d. Decreased urine output

b. Increased thirst

The nurse is discharging a client after an arthroscopy. The nurse needs to teach the client to watch for which potential complications? Select all that apply. a. Backache b. Infection c. Swelling d. Thrombophlebitis e. Decreased appetite f. Increased joint pain related to mechanical injury

b. Infection c. Swelling d. Thrombophlebitis f. Increased joint pain related to mechanical injury

The nurse has developed a postoperative plan of care for a client who had a thyroidectomy and documents that the client is at risk for developing an ineffective breathing pattern. Which nursing intervention should the nurse include in the plan of care? a. Maintain a supine position. b. Monitor neck circumference every 4 hours. c. Maintain a pressure dressing on the operative site. d. Encourage deep-breathing exercises and vigorous coughing exercises.

b. Monitor neck circumference every 4 hours.

A client is receiving an intravenous infusion of 1000 mL of normal saline with 40 mEq of potassium chloride. The care unit nurse is monitoring the client for signs of hyperkalemia. Which finding initially will be noted in the client if hyperkalemia is present? a. Confusion b. Muscle weakness c. Mental status changes d. Depressed deep tendon reflexes

b. Muscle weakness

The nurse is caring for a client who is 2 days postoperative from abdominal hysterectomy. The client has a history of diabetes mellitus and has been receiving regular insulin based on capillary blood glucose testing 4 times a day. A carbohydrate-controlled diet has been prescribed, but the client has not been eating. On entering the client's room, the nurse finds the client to be pale and diaphoretic. Which action is appropriate at this time? a. Call a code to obtain needed assistance immediately. b. Obtain a capillary blood glucose level and quickly perform a focused assessment. c. Ask the unlicensed assistive personnel (UAP) to stay with the client while obtaining a carbohydrate snack for the client to eat. d. Stay with the client and ask the UAP to call the health care provider (HCP) for a prescription for intravenous 50% dextrose.

b. Obtain a capillary blood glucose level and quickly perform a focused assessment.

The nurse caring for a client with a diagnosis of hypoparathyroidism reviews the laboratory results of blood tests for this client and notes that the calcium level is extremely low. The nurse should expect to note which finding on assessment of the client? a. Unresponsive pupils b. Positive Trousseau's sign c. Negative Chvostek's sign d. Hypoactive bowel sounds

b. Positive Trousseau's sign

Spironolactone is prescribed for a client with heart failure. In providing dietary instructions to the client, the nurse identifies the need to avoid foods that are high in which electrolyte? a. Calcium b. Potassium c. Magnesium d. Phosphorus

b. Potassium

The nurse is preparing for a client's postoperative return to the unit after a parathyroidectomy procedure. The nurse should ensure that which piece of medical equipment is at the client's bedside? a. Cardiac monitor b. Tracheotomy set c. Intermittent gastric suction device d. Underwater seal chest drainage system

b. Tracheotomy set

A client has a history fo heart failure and has been on furosemide (Lasix), digosin (Lanoxin), and potassium chloride. The client has nausea, blurred vision, headache, and weakness. he nurse notes that the client is confused. The telemetry strop shows first-degree AV-block. The nurse should assess the client for signs of which of the followin? a. hyperkalemia b. digoxin toxicity c. fluid deficit d. pulmonary edema

b. digoxin toxicity

The nurse is caring for a client with heart failure. On assessment, the nurse notes that the client is dyspneic, and crackles are audible on auscultation. What additional manifestations would the nurse expect to note in this client if excess fluid volume is present? a. Weight loss and dry skin b. Flat neck and hand veins and decreased urinary output c. An increase in blood pressure and increased respirations d. Weakness and decreased central venous pressure (CVP)

c. An increase in blood pressure and increased respirations

The nurse is assisting in the care of a client with pheochromocytoma who has been experiencing clinical manifestations of hypermagnesemia. When evaluating the client, the nurse should determine that the client's status is returning to normal if which is no longer exhibited? a. Tetany b. Tremors c. Areflexia d. Muscular excitability

c. Areflexia

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry for a preoperative client. The nurse should perform which best action to ensure accurate readings on the oximeter? a. Apply the sensor to a finger that is cool to the touch. b. Apply the sensor to a finger with very dark nail polish. c. Ask the client to limit motion in the hand attached to the pulse oximeter. d. Place the sensor distal to an intravenous (IV) site with a continuous IV infusion.

c. Ask the client to limit motion in the hand attached to the pulse oximeter.

A client is brought to the emergency department in an unresponsive state, and a diagnosis of hyperosmolar hyperglycemic syndrome is made. The nurse would immediately prepare to initiate which anticipated health care provider's prescription? a. Endotracheal intubation b. 100 units of NPH insulin c. Intravenous infusion of normal saline d. Intravenous infusion of sodium bicarbonate

c. Intravenous infusion of normal saline

The nurse is caring for a client after thyroidectomy. The client expresses concern about the postoperative voice hoarseness she is experiencing and asks if the hoarseness will subside. The nurse should provide the client with which information? a. It indicates nerve damage. b. The hoarseness is permanent. c. It is normal during this time and will subside. d. It will worsen before it subsides, which may take 6 months.

c. It is normal during this time and will subside.

A nurse is assisting a client with diabetes mellitus who is recovering from diabetic ketoacidosis (DKA) to develop a plan to prevent a recurrence. Which is most important to include in the plan of care? a. Test urine for ketone levels. b. Eat 6 small meals per day. c. Monitor blood glucose levels frequently. d. Receive appropriate follow-up health care.

c. Monitor blood glucose levels frequently.

An operating room nurse is positioning a client on the operating room table to prevent the client's extremities from dangling over the sides of the table. A nursing student who is observing for the day asks the nurse why this is so important. The nurse responds that this is done primarily to prevent which condition? a. An increase in pulse rate b. A drop in blood pressure c. Nerve and muscle damage d. Muscle fatigue in the extremities

c. Nerve and muscle damage

The nurse is obtaining a pulse oximetry reading from a postoperative client who appears short of breath. The client has dark fingernail polish on top of artificial nails. What is the most appropriate action? a. Take the pulse oximetry reading from any finger. b. Remove one of the artificial nails and then obtain the reading from the finger. c. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe. d. Obtain fingernail polish remover, remove the polish, and then obtain the pulse oximetry reading from a finger.

c. Obtain a pulse oximetry reading from another appropriate area, such as an earlobe.

The nurse is caring for a client the day after a left total knee arthroplasty surgery. In reviewing the client's past medical history, the nurse notes that the client has a history of urinary incontinence and heart failure, which is managed with a potassium-retaining diuretic and a beta-adrenergic blocker. Which prescription, if not already prescribed, should the nurse contact the health care provider to obtain? a. Daily electrolytes b. A 12-lead electrocardiogram c. Resume the client's dose of metoprolol d. Insertion of an indwelling urinary catheter

c. Resume the client's dose of metoprolol

A client has returned to the nursing unit after an abdominal hysterectomy. The client is lying supine. To thoroughly assess the client for postoperative bleeding, what is the primary nursing action? a. Check the heart rate. b. Check the blood pressure. c. Roll the client to one side and check her perineal pad. d. Ask the client about sensation of moistness on her perineal pad.

c. Roll the client to one side and check her perineal pad.

A client with type 1 diabetes mellitus is to begin an exercise program, and the nurse is providing instructions regarding the program. Which instruction should the nurse include in the teaching plan? a. Try to exercise before mealtimes. b. Administer insulin after exercising. c. Take a blood glucose test before exercising. d. Exercise is best performed during peak times of insulin.

c. Take a blood glucose test before exercising.

A client has received atropine sulfate intravenously during a surgical procedure. The nurse should monitor the client for which side effect of the medication in the immediate postoperative period? a. Diarrhea b. Bradycardia c. Urinary retention d. Excessive salivation

c. Urinary retention

The nurse teaches a client who has recently been diagnosed with HTN about following a low-calorie, low-fat, low-sodium diet. Which of the following menu selections would best meet the client's needs? a. mixed green salad with blue cheese dressing, crackers, and cold cuts b. ham sandwich on rye bread and an orange c. baked chicken, an apple, and a slice of white bread d. hot dogs, baked beans, and celery and carrot sticks

c. baked chicken, an apple, and a slice of white bread

A client with type 1 diabetes mellitus is having trouble remembering the types, duration, and onset of the action of insulin. The client tells the nurse that family members have not been supportive. Which response by the nurse is best? a. "What is it that you don't understand?" b. "You can't always depend on your family to help." c. "It's not really necessary for you to remember this." d. "Let me go over the types of insulins with you again."

d. "Let me go over the types of insulins with you again."

The nurse provides instructions to a preoperative client about the use of an incentive spirometer. The nurse determines that the client needs further instruction if the client indicates that he or she will take which action? a. Sit upright when using the device. b. Inhale slowly, maintaining a constant flow. c. Place the lips completely over the mouthpiece. d. After maximal inspiration, hold the breath for 10 seconds and then exhale.

d. After maximal inspiration, hold the breath for 10 seconds and then exhale.

After hypophysectomy, a client complains of being thirsty and having to urinate frequently. What is the initial nursing action? a. Increase fluid intake. b. Document the complaints. c. Assess for urinary glucose. d. Assess urine specific gravity.

d. Assess urine specific gravity.

The nurse prepares a client 1 hour prior to surgery. Which assessment finding does the nurse need to communicate to the health care provider (HCP) at this time? a. Allergy to peanuts b. Potassium is 3.6 mEq/L (3.6 mmol/L) c. History of obstructive sleep apnea d. Daily garlic capsules, last dose yesterday morning

d. Daily garlic capsules, last dose yesterday morning

A client with type 2 diabetes mellitus has a blood glucose level greater than 600 mg/dL (34.3 mmol/L) and is complaining of polydipsia, polyuria, weight loss, and weakness. The nurse reviews the health care provider's documentation and expects to note which diagnosis? a. Hypoglycemia b. Pheochromocytoma c. Diabetic ketoacidosis (DKA) d. Hyperosmolar hyperglycemic syndrome (HHS)

d. Hyperosmolar hyperglycemic syndrome (HHS)

A client with type 2 diabetes mellitus is complaining of polydipsia, polyuria, weight loss, and weakness. Laboratory results indicate a blood glucose level of 800 mg/dL (45.7 mmol/L) and nonketosis. The nurse reviews the health care provider's documentation and expects to note which diagnosis? a. Hypoglycemia b. Pheochromocytoma c. Diabetic ketoacidosis (DKA) d. Hyperosmolar hyperglycemic syndrome (HHS)

d. Hyperosmolar hyperglycemic syndrome (HHS)

A client needs to be placed on strict intake and output (I&O) measurement. The nurse collects the data and then checks the client's skin turgor by taking which action? a. Pinching the skin on the thigh b. Pushing on the skin in the ankle area c. Assessing the skin in the radial pulse area d. Pulling up and releasing the skin on the sternal area

d. Pulling up and releasing the skin on the sternal area

The nurse is monitoring a diabetic client with a blood glucose level of 400 mg/dL (22.2 mmol/L). Which clinical manifestation would indicate diabetic ketoacidosis (DKA)? a. Bradycardia b. Cool, clammy skin c. Lower extremity edema d. Rapid, deep respirations

d. Rapid, deep respirations

The nurse is caring for a client who recently returned from the operating room. On data collection, the nurse notes that the client's vital signs are blood pressure (BP), 118/70 mm Hg; pulse, 91 beats/minute; and respirations, 16 breaths/minute. Preoperative vital signs were BP, 132/88 mm Hg; pulse, 74 beats/minute; and respirations, 20 breaths/minute. Which action should the nurse plan to take first? a. Call the surgeon immediately. b. Shake the client gently to arouse. c. Cover the client with a warm blanket. d. Recheck the vital signs in 15 minutes.

d. Recheck the vital signs in 15 minutes.

A test to measure long-term control of diabetes mellitus has been prescribed for a client. In instructing the client about the test, the nurse explains that long-term control can be measured because chronic high blood glucose levels lead to irreversible glucose binding onto what? a. Platelets b. Muscle tissue c. Adipose tissue d. Red blood cells (RBCs)

d. Red blood cells (RBCs)

The blood glucose of a patient who is newly diagnosed with type 1 diabetes mellitus has a blood glucose level of 340 mg/dL. Which type of insulin prescribed for the patient is appropriate to administer at this time? a. NPH + regular (70/30) b. Glargine c. NPH d. Regular

d. Regular

A client has just returned to a nursing unit after an above-knee amputation of the right leg. The nurse should place the client in which position? a. Prone b. Reverse Trendelenburg's c. Supine, with the residual limb flat on the bed d. Supine, with the residual limb supported with pillows

d. Supine, with the residual limb supported with pillows

The nurse teaches a client with heart failure to take oral furosemide in the morning. The primary reason for this is to help: a. prevent electrolyte imbalances b. retard repid drug absorption c. excrete excessive fluids accumulated during the night d. prevent sleep disturbances during the night

d. prevent sleep disturbances during the night

Furosemide is administered intravenously to a pt with heart failure. How soon after administration should the nurse begin to see evidence of the drugs desired effect? 1. 5 to 10 min 2. 30 to 60 min 3. 2 to 4 hours 4. 6 to 8 hours

1. 5 to 10 min

The nurse is preparing to care for a client with a potassium deficit. The nurse reviews the client's record and determines that the client is at risk for developing the potassium deficit because of which situation? a. Sustained tissue damage b. Requires nasogastric suction c. Has a history of Addison's disease d. Uric acid level of 9.4 mg/dL (559 mmol/L)

b. Requires nasogastric suction

On review of the clients' medical records, the nurse determines that which client is at risk for fluid volume excess? a. The client taking diuretics and has tenting of the skin b. The client with an ileostomy from a recent abdominal surgery c. The client who requires intermittent gastrointestinal suctioning d. The client with kidney disease and a 12-year history of diabetes mellitus

d. The client with kidney disease and a 12-year history of diabetes mellitus

During routine nursing assessment after hypophysectomy, a client complains of thirst and frequent urination. Knowing the expected complications of this surgery, what should the nurse assess next? a. Serum glucose b. Blood pressure c. Respiratory rate d. Urine specific gravity

d. Urine specific gravity

The nurse is monitoring the fluid balance of a client with a burn injury. The nurse determines that the client is less than adequately hydrated if which information is noted during assessment? a. Urine pH of 6 b. Urine that is pale yellow c. Urine output of 40 mL/hr d. Urine specific gravity of 1.032

d. Urine specific gravity of 1.032

What is the onset and peak for NPH insulin?

onset: 2-4 hours peak: 4-12 hours

What is the onset and peak for regular insulin?

onset: 30-60 mins peak: 2-4 hrs

An ambulatory care nurse measures the blood pressure of a client and finds it to be 156/94 mm Hg. Which statement indicates that the client needs additional education? a. "It is important that I limit protein intake." b. "I need to maintain a regular exercise program." c. "I understand that I need to avoid adding salt to foods." d. "It is important that I begin reducing and then maintaining weight."

a. "It is important that I limit protein intake."

The nurse is teaching a client about coughing and deep-breathing techniques to prevent postoperative complications. Which statement is most appropriate for the nurse to make to the client at this time as it relates to these techniques? a. "Use of an incentive spirometer will help prevent pneumonia." b. "Close monitoring of your oxygen saturation will detect hypoxemia." c. "Administration of intravenous fluids will prevent or treat fluid imbalance." d. "Early ambulation and administration of blood thinners will prevent pulmonary embolism."

a. "Use of an incentive spirometer will help prevent pneumonia."

A client received 5 units of insulin aspart subcutaneously just before eating lunch at 12:00 p.m. The nurse should assess the client for a hypoglycemic reaction at which times? a. Between 1:00 and 3:00 p.m. b. 10 minutes after administration c. Between 4:00 p.m. and 12:00 a.m. d. Between 8:00 and 10:00 p.m.

a. Between 1:00 and 3:00 p.m.

A client visits the health care provider's office for a routine physical examination and reports a new onset of intolerance to cold. Since hypothyroidism is suspected, which additional information would be noted during the client's assessment? a. Weight loss and tachycardia b. Complaints of weakness and lethargy c. Diaphoresis and increased hair growth d. Increased heart rate and respiratory rate

b. Complaints of weakness and lethargy

The nurse is assessing the client's use of medications. Which of the following medications may cause a complication with the treatment plan of a client with diabetes? a. Angiotensin-converting enzyme (ACE) inhibitors. b. Sulfonylureas. c. Aspirin. d. Steroids.

d. Steroids.

The nurse has provided dietary instructions to a client with a diagnosis of hypoparathyroidism. The nurse should instruct the client that it is acceptable to include which item in the diet? a. Fish b. Cereals c. Vegetables d. Meat and poultry

c. Vegetables

The home health nurse visits a client with a diagnosis of type 1 diabetes mellitus. The client relates a history of vomiting and diarrhea and tells the nurse that no food has been consumed for the last 24 hours. Which additional statement by the client indicates a need for further teaching? a. "I need to stop my insulin." b. "I need to increase my fluid intake." c. "I need to monitor my blood glucose every 3 to 4 hours." d. "I need to call the health care provider (HCP) because of these symptoms."

a. "I need to stop my insulin."

The nurse is caring for a client with a new diagnosis of hypothyroidism. Which clinical manifestations might the nurse expect to note on examination of this client? (Select all that apply.) a. Irritability b. Periorbital edema c. Coarse, brittle hair d. Slow or slurred speech e. Abdominal distention f. Soft, silky, thinning hair

b. Periorbital edema c. Coarse, brittle hair d. Slow or slurred speech e. Abdominal distention

The nurse is assessing the learning readiness of a client newly diagnosed with diabetes mellitus. Which behavior indicates to the nurse that the client is not ready to learn? a. The client asks if the spouse may attend the teaching session. b. The client asks appropriate questions about what will be taught. c. The client asks for written materials about diabetes mellitus before class. d. The client complains of fatigue whenever the nurse plans a teaching session.

d. The client complains of fatigue whenever the nurse plans a teaching session.

Which client is at risk for the development of a potassium level of 5.5 mEq/L (5.5 mmol/L)? a. The client with colitis b. The client with Cushing's syndrome c. The client who has been overusing laxatives d. The client who has sustained a traumatic burn

d. The client who has sustained a traumatic burn

The nurse should assess the client for digoxin toxicity if serum levels indicate that the client has a: a. low sodium level b. high glucose level c. high calcium level d. low potassium level

d. low potassium level

A client has just been admitted to the nursing unit following thyroidectomy. Which assessment is the priority for this client? a. Hypoglycemia b. Level of hoarseness c. Respiratory distress d. Edema at the surgical site

c. Respiratory distress

The nurse is assessing a client who has a diagnosis of goiter. Which should the nurse expect to note during the assessment of the client? a. An enlarged thyroid gland b. The presence of heart damage c. Client complaints of chronic fatigue d. Client complaints of slow wound healing

a. An enlarged thyroid gland

A client is recovering well 24 hours after cranial surgery but is fatigued. The surgeon advances the client from nothing-by-mouth status to clear liquids. The nurse knows that which information is least reliable in determining the client's readiness to take in fluids? a. Appetite b. Absence of nausea c. Presence of bowel sounds d. Presence of a swallow reflex

a. Appetite

The nurse is caring for a client who needs a hypertonic intravenous (IV) solution. What solutions are hypertonic? (Select all that apply.) a. 10% dextrose in water b. 0.45% sodium chloride c. 5% dextrose in 0.9% saline d. 5% dextrose in 0.45% saline e. 5% dextrose in 0.225% saline f. 5% dextrose in lactated Ringer's solution

a. 10% dextrose in water c. 5% dextrose in 0.9% saline d. 5% dextrose in 0.45% saline f. 5% dextrose in lactated Ringer's solution

The nurse is assigned to care for a group of clients. On review of the clients' medical records, the nurse determines that which client is most likely at risk for a fluid volume deficit? a. A client with an ileostomy b. A client with heart failure c. A client on long-term corticosteroid therapy d. A client receiving frequent wound irrigations

a. A client with an ileostomy

A client with diabetes mellitus who takes insulin is seen in the health care clinic. The client tells the clinic nurse that after the insulin injection, the insulin seems to leak through the skin. The nurse would appropriately determine the problem by asking the client which question? a. "Are you rotating the injection site?" b. "Are you aspirating before you inject the insulin?" c. "Are you using a 1-inch needle to give the injection?" d. "Are you placing an air bubble in the syringe before injection?"

a. "Are you rotating the injection site?"

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided? a. "I will eat enough daily fiber to prevent straining at stool." b. "I will try to exercise vigorously to strengthen my heart muscle." c. "I will drink 3000 to 3500 mL of fluid daily to promote good kidney function." d. "Drinking 2 to 3 oz of liquor each night will promote blood flow by enlarging blood vessels."

a. "I will eat enough daily fiber to prevent straining at stool."

The nurse is preparing a client for surgery scheduled in two hours. Which interventions are appropriate in the preoperative period? (Select all that apply.) a. Assist the client to void before transfer to the operating room. b. Check all surgeon's prescriptions to ensure they have been carried out. c. Teach postoperative breathing exercises before the client is premedicated. d. Review the client's record for a history and physical report and laboratory reports. e. Administer all the daily medications 2 hours before the scheduled time of the surgery.

a. Assist the client to void before transfer to the operating room. b. Check all surgeon's prescriptions to ensure they have been carried out. d. Review the client's record for a history and physical report and laboratory reports.

The nurse is reviewing the health care provider's prescription sheet for a preoperative client, which states that the client must be NPO (nothing by mouth) after midnight. Which medication should the nurse clarify to be given and not withheld? a. Atenolol b. Atorvastatin c. Cyclobenzaprine d. Conjugated estrogen

a. Atenolol

The nurse caring for a client who underwent intracranial surgery is suspected of having diabetes insipidus. Which finding noted by the nurse is consistent with this complication of surgery? a. Complaints of excessive thirst b. Urine specific gravity of 1.030 c. Urine output of 10 to 15 mL/hour d. Systolic blood pressures running consistently over 150 mm Hg

a. Complaints of excessive thirst

A client who has had abdominal surgery complains of feeling as though "something gave way" in the incisional site. The nurse removes the dressing and notes the presence of a loop of bowel protruding through the incision. Which interventions should the nurse take? Select all that apply. a. Contact the surgeon. b. Instruct the client to remain quiet. c. Prepare the client for wound closure. d. Document the findings and actions taken. e. Place a sterile saline dressing and ice packs over the wound. f. Place the client in a supine position without a pillow under the head.

a. Contact the surgeon. b. Instruct the client to remain quiet. c. Prepare the client for wound closure. d. Document the findings and actions taken.

During an assessment of a newly admitted client, the nurse notes that the client's heart rate is 110 beats/minute, his blood pressure shows orthostatic changes when he stands up, and his tongue has a sticky, paste-like coating. The client's spouse tells the nurse that he seems a little confused and unsteady on his feet. Based on these assessment findings, the nurse suspects that the client has which condition? a. Dehydration b. Hypokalemia c. Fluid overload d. Hypernatremia

a. Dehydration

A client who is at risk for fluid imbalance is to be admitted to the nursing unit. In planning care for this client, the nurse is aware that which conditions cause the release of antidiuretic hormone (ADH)? (Select all that apply.) a. Dehydration b. Hypertension c. Physiological stress d. Decreased blood volume e. Decreased plasma osmolarity

a. Dehydration c. Physiological stress d. Decreased blood volume

The nurse is updating the client's plan of care based on the new onset of hypokalemia. Which priorities of care should the nurse include? (Select all that apply.) a. Ensure adequate oxygenation. b. Provide assistance to prevent falls. c. Monitor medication administration of diuretics. d. Monitor for numbness and tingling around the mouth. e. Prevent complications during potassium administration.

a. Ensure adequate oxygenation. b. Provide assistance to prevent falls. c. Monitor medication administration of diuretics. e. Prevent complications during potassium administration.

The nurse is preparing a preoperative client for transfer to the operating room. The nurse should take which action in the care of this client at this time? a. Ensure that the client has voided. b. Administer all the daily medications. c. Verify that the client has not eaten for the past 24 hours. d. Have the client practice postoperative breathing exercises.

a. Ensure that the client has voided.

A client has been diagnosed with hyperthyroidism. The nurse monitors for which signs and symptoms indicating a complication of this disorder? (Select all that apply.) a. Fever b. Nausea c. Lethargy d. Tremors e. Confusion f. Bradycardia

a. Fever b. Nausea d. Tremors e. Confusion

The nurse is monitoring a client with Graves' disease for signs of thyrotoxic crisis (thyroid storm). Which signs or symptoms, if noted in the client, will alert the nurse to the presence of this crisis? a. Fever and tachycardia b. Pallor and tachycardia c. Agitation and bradycardia d. Restlessness and bradycardia

a. Fever and tachycardia

A client with diabetes mellitus is being tested to determine long-term diabetic control. Which result should the nurse expect to see if the client's long-term control is within acceptable limits? a. Glycosylated hemoglobin of <6% b. Presence of ketones in the urine c. Presence of albumin in the urine d. Fasting blood glucose level of 150 mg/dL (8.57 mmol/L)

a. Glycosylated hemoglobin of <6%

A nurse is caring for a client who had a thyroidectomy 1 day ago. Which client laboratory data should the nurse identify as a possible complication of thyroid surgery? a. Increased serum sodium level b. Increased serum glucose level c. Decreased serum calcium level d. Decreased serum albumin level

c. Decreased serum calcium level

The nurse is admitting a client who is diagnosed with syndrome of inappropriate antidiuretic hormone secretion (SIADH) and has serum sodium of 118 mEq/L (118 mmol/L). Which health care provider prescriptions should the nurse anticipate receiving? (Select all that apply.) a. Initiate an infusion of 3% NaCl. b. Administer intravenous furosemide. c. Restrict fluids to 800 mL over 24 hours. d. Elevate the head of the bed to high Fowler's. e. Administer a vasopressin antagonist as prescribed.

a. Initiate an infusion of 3% NaCl. c. Restrict fluids to 800 mL over 24 hours. e. Administer a vasopressin antagonist as prescribed.

A client is admitted with a serum glucose level of 650 mg/dL (37.14 mmol/L) and diabetic ketoacidosis (DKA) is suspected. Which additional laboratory result does the nurse identify as being supportive of DKA? a. Ketones in urine b. Lactic dehydrogenase (LDH) of 200 U/L c. pH of 7.52 on arterial blood gas (ABG) analysis d. Blood urea nitrogen (BUN) of 10 mg/dL (3.6 mmol/L)

a. Ketones in urine

A nurse is assessing the status of a client who returned to the surgical nursing unit after a parathyroidectomy procedure. The nurse would place highest priority on which assessment finding? a. Laryngeal stridor b. Difficulty voiding c. Mild incisional pain d. Absence of bowel sounds

a. Laryngeal stridor

A nurse is assessing the glycemic status of a client with diabetes mellitus. Which sign or symptom would indicate that the client is developing hyperglycemia? a. Polyuria b. Diaphoresis c. Hypertension d. Increased pulse rate

a. Polyuria

The nurse is monitoring a client newly diagnosed with diabetes mellitus for signs of complications. Which sign or symptom, if exhibited in the client, indicates that the client is at risk for chronic complications of diabetes if the blood glucose is not adequately managed? a. Polyuria b. Diaphoresis c. Pedal edema d. Decreased respiratory rate

a. Polyuria

The nurse is caring for a client with a diagnosis of diabetic ketoacidosis (DKA). Which assessment findings are consistent with this diagnosis? (Select all that apply.) a. Polyuria b. Polydipsia c. Polyphagia d. Dry mouth e. Flushed, dry skin f. Moist mucous membranes

a. Polyuria b. Polydipsia c. Polyphagia d. Dry mouth e. Flushed, dry skin

A nurse is reviewing the assessment findings for a client who was admitted to the hospital with a diagnosis of diabetes insipidus. The nurse understands that which manifestations are associated with this disorder? Select all that apply. a. Polyuria b. Polydipsia c. Concentrated urine d. Complaints of excessive thirst e. Specific gravity lower than 1.005

a. Polyuria b. Polydipsia d. Complaints of excessive thirst e. Specific gravity lower than 1.005

The nurse is completing an assessment on a client who is being admitted for a diagnostic workup for primary hyperparathyroidism. Which client complaint would be characteristic of this disorder? (Select all that apply.) a. Polyuria b. Headache c. Bone pain d. Nervousness e. Weight gain

a. Polyuria c. Bone pain

The nurse is reviewing a surgeon's prescription sheet for a preoperative client that states that the client must be nothing by mouth (NPO) after midnight. The nurse should call the surgeon to clarify that which medication should be given to the client and not withheld? a. Prednisone b. Ferrous sulfate c. Cyclobenzaprine d. Conjugated estrogen

a. Prednisone

A client with diabetes mellitus is being discharged following treatment for hyperosmolar hyperglycemic syndrome (HHS) precipitated by acute illness. The client tells the nurse, "I will call the health care provider (HCP) the next time I can't eat for more than a day or so." Which statement reflects the most appropriate analysis of this client's level of knowledge? a. The client needs immediate education before discharge. b. The client requires follow-up teaching regarding the administration of oral antidiabetics. c. The client's statement is inaccurate, and he or she should be scheduled for outpatient diabetic counseling. d. The client's statement is inaccurate, and he or she should be scheduled for educational home health visits.

a. The client needs immediate education before discharge.

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? a. Urinary output of 20 mL/hour b. Temperature of 37.6°C (99.6°F) c. Blood pressure of 100/70 mm Hg d. Serous drainage on the surgical dressing

a. Urinary output of 20 mL/hour

The nurse teaches a class on foot care for clients diagnosed with diabetes mellitus. Which instructions should the nurse include in the class? (Select all that apply.) a. Wear closed-toe shoes. b. Soak feet in hot water twice a day. c. Massage lanolin lotion between the toes. d. Cut toenails straight across and file the edges. e. Pat feet dry gently, especially between the toes.

a. Wear closed-toe shoes. d. Cut toenails straight across and file the edges. e. Pat feet dry gently, especially between the toes.

The nurse is taking a health history for a client with hyperparathyroidism. Which question would elicit information about this client's condition? a. "Do you have tremors in your hands?" b. "Are you experiencing pain in your joints?" c. "Do you notice swelling in your legs at night?" d. "Have you had problems with diarrhea lately?"

b. "Are you experiencing pain in your joints?"

The nurse has provided instructions to the client with hyperparathyroidism regarding home care measures to manage the symptoms of the disease. Which statement by the client indicates a need for further instruction? a. "I should avoid bed rest." b. "I need to avoid doing any exercise at all." c. "I need to space activity throughout the day." d. "I should gauge my activity level by my energy level."

b. "I need to avoid doing any exercise at all."

The nurse has provided home care measures to the client with diabetes mellitus regarding exercise and insulin administration. Which statement by the client indicates a need for further instruction? a. "I should always wear a MedicAlert bracelet." b. "I should perform my exercise at peak insulin time." c. "I should always carry a quick-acting carbohydrate when I exercise." d. "I should avoid exercising at times when a hypoglycemic reaction is likely to occur."

b. "I should perform my exercise at peak insulin time."

An 85-year-old client is hospitalized for a fractured right hip. During the postoperative period, the client's appetite is poor and the client refuses to get out of bed. Which nursing statement would be most appropriate to make to the client? a. "We need to give you iodine to help in hemoglobin synthesis." b. "It is important for you to get out of bed so that calcium will go back into the bone." c. "We need to increase your calcium intake because you are spending too much time in bed." d. "You need to remember to turn yourself in bed every 2 hours to keep from getting so stiff."

b. "It is important for you to get out of bed so that calcium will go back into the bone."

A client with type 1 diabetes mellitus calls the nurse to report recurrent episodes of hypoglycemia with exercising. Which statement by the client indicates an adequate understanding of the peak action of NPH insulin and exercise? a. "I should not exercise since I am taking insulin." b. "The best time for me to exercise is after breakfast." c. "The best time for me to exercise is mid- to late afternoon." d. "NPH is a basal insulin, so I should exercise in the evening."

b. "The best time for me to exercise is after breakfast."

The home care nurse is visiting a client newly diagnosed with diabetes mellitus. The client tells the nurse that he is planning to eat dinner at a local restaurant this week. The client asks the nurse if eating at a restaurant will affect diabetic control and if this is allowed. Which nursing response is most appropriate? a. "You are not allowed to eat in restaurants." b. "You should order a half-portion meal and have fresh fruit for dessert." c. "If you plan to eat in a restaurant, you need to skip the lunchtime meal." d. "You should increase your daily dose of insulin by half on the day that you plan to eat in the restaurant."

b. "You should order a half-portion meal and have fresh fruit for dessert."

A client with diabetes mellitus has a blood glucose level of 50 mg/dL (2.85 mmol/L) and reports feeling hungry and shaky. Which should the nurse provide the client? a. 3 oz of 2% milk b. 4 oz of apple juice c. 2 oz of orange juice d. A teaspoon of granulated sugar

b. 4 oz of apple juice

The nursing instructor asks a nursing student to identify the risk factors associated with the development of thyrotoxicosis. The student demonstrates understanding of the risk factors by identifying an increased risk for thyrotoxicosis in which client? a. A client with hypothyroidism b. A client with Graves' disease who is having surgery c. A client with diabetes mellitus scheduled for a diagnostic test d. A client with diabetes mellitus scheduled for debridement of a foot ulcer

b. A client with Graves' disease who is having surgery

The nurse is caring for a client with a diagnosis of dehydration, and the client is receiving intravenous (IV) fluids. Which assessment finding would indicate to the nurse that the dehydration remains unresolved? a. An oral temperature of 98.8°F (37.1°C) b. A urine specific gravity of 1.043 c. A urine output that is pale yellow d. A blood pressure of 120/80 mm Hg

b. A urine specific gravity of 1.043

The nurse is preparing to care for a client after parathyroidectomy. The nurse should plan for which action for this client? a. Maintain an endotracheal tube for 24 hours. b. Administer a continuous mist of room air or oxygen. c. Place the client in a flat position with the head and neck immobilized. d. Use only a rectal thermometer for temperature measurement.

b. Administer a continuous mist of room air or oxygen.

Which assessment finding indicates that a client who had a mastectomy is experiencing a complication related to the surgery? a. Pain at the incisional site b. Arm edema on the operative side c. Sanguineous drainage in the Jackson-Pratt drain d. Complaints of decreased sensation near the operative site

b. Arm edema on the operative side

The nurse has a prescription to remove the nasogastric (NG) tube from a client on the first postoperative day after cardiac surgery. The nurse should question the prescription if which finding was noted on assessment of the client? a. The client is drowsy. b. Bowel sounds are absent. c. The abdomen is slightly distended. d. NG tube drainage is Hematest negative.

b. Bowel sounds are absent.

A client has returned to the nursing unit after a thyroidectomy. The nurse notes that the client is complaining of tingling sensations around the mouth, fingers, and toes. On the basis of these findings, the nurse should next assess the results of which serum laboratory study? a. Sodium b. Calcium c. Potassium d. Magnesium

b. Calcium

A home health nurse is visiting a client with type 1 diabetes mellitus. The client tells the nurse that he is not feeling well and has had a "respiratory infection" for the past week, which seems to be getting worse. After interviewing the client, what should be the initial nursing action? a. Document the assessment data. b. Check the client's blood glucose. c. Notify the health care provider (HCP). d. Obtain the client's sputum for culture and sensitivity.

b. Check the client's blood glucose.

A client with a diagnosis of diabetic ketoacidosis (DKA) is being treated in the emergency department. Which findings support this diagnosis? Select all that apply. a. Increase in pH b. Comatose state c. Deep, rapid breathing d. Decreased urine output e. Elevated blood glucose level

b. Comatose state c. Deep, rapid breathing e. Elevated blood glucose level

The nurse is caring for an abdominal surgical client who has a Jackson-Pratt drain in place. Which interventions should the nurse include in the plan of care for this drain? (Select all that apply.) a. Secure the drain to the sheet. b. Make sure suction is maintained. c. Check that the drains are sutured in place. d. Use clean technique to empty the reservoir. e. Compress the reservoir to restore suction after emptying. f. Record the amount and color of drainage according to agency protocol or health care provider's orders.

b. Make sure suction is maintained. c. Check that the drains are sutured in place. e. Compress the reservoir to restore suction after emptying. f. Record the amount and color of drainage according to agency protocol or health care provider's orders.

The nurse in a health care clinic is reviewing the record of a client with diabetes mellitus who was just seen by the health care provider (HCP). The nurse notes that the HCP has prescribed acarbose. Which preexisting disorder, if noted in the client's record, would indicate a contraindication to the use of this medication? a. Hypothyroidism b. Renal insufficiency c. Arterial insufficiency d. Coronary artery disease

b. Renal insufficiency

The nurse assesses a client's surgical incision for signs of infection. Which finding by the nurse would be interpreted as a normal finding at the surgical site? a. Red, hard skin b. Serous drainage c. Purulent drainage d. Warm, tender skin

b. Serous drainage

The nurse is providing preoperative teaching to a client scheduled for a cholecystectomy. Which intervention would be of highest priority in the preoperative teaching plan? a. Teaching leg exercises b. Teaching coughing and deep breathing exercises c. Providing instructions regarding fluid restrictions d. Assessing the client's understanding of the surgical procedure

b. Teaching coughing and deep breathing exercises

A nurse is caring for a client after a thyroidectomy. Which specific emergency equipment should the nurse have available as it relates to this procedure? a. Defibrillator b. Tracheostomy tray c. Dextrose 50% in water d. Normal saline for intravenous bolus

b. Tracheostomy tray

The nurse is caring for a 25-year-old client who will undergo bilateral orchidectomy for testicular cancer. Which statement by the nurse would be helpful in exploring the client's concerns about loss of reproductive ability? a. "You must be sad that you won't be able to have children after surgery." b. "Has the health care provider told you that you will not be able to have children?" c. "Can you share with me any concerns about how this surgery will affect you in the future?" d. "Do you feel that the health care provider has told you all you need to know about the upcoming surgery?"

c. "Can you share with me any concerns about how this surgery will affect you in the future?"

A preoperative client expresses anxiety to the nurse about upcoming surgery. Which response by the nurse is most likely to stimulate further discussion between the client and the nurse? a. "If it's any help, everyone is nervous before surgery." b. "I will be happy to explain the entire surgical procedure to you." c. "Can you share with me what you've been told about your surgery?" d. "Let me tell you about the care you'll receive after surgery and the amount of pain you can anticipate."

c. "Can you share with me what you've been told about your surgery?"

The nurse has conducted preoperative teaching for a client scheduled for surgery in 1 week. The client has a history of arthritis and has been taking acetylsalicylic acid. The nurse determines that the client needs additional teaching if the client makes which statement? a. "Aspirin can cause bleeding after surgery." b. "Aspirin can cause my ability to clot blood to be abnormal." c. "I need to continue to take the aspirin until the day of surgery." d. "I need to check with my health care provider about the need to stop the aspirin before the scheduled surgery."

c. "I need to continue to take the aspirin until the day of surgery."

The nurse is providing instructions regarding home care measures to a client with diabetes mellitus and instructs the client about the causes of hypoglycemia. The nurse determines that additional instruction is needed if the client identifies which as a cause of hypoglycemia? a. Omitted meals b. Increased intensity of activity c. Decreased daily insulin dosage d. Inadequate amount of fluid intake

c. Decreased daily insulin dosage

The nurse is caring for a client who is scheduled to have a thyroidectomy and provides instructions to the client about the surgical procedure. Which client statement indicates an understanding of the nurse's instructions? a. "I expect to experience some tingling of my toes, fingers, and lips after surgery." b. "I will definitely have to continue taking antithyroid medications after this surgery." c. "I need to place my hands behind my neck when I have to cough or change positions." d. "I need to turn my head and neck front, back, and laterally every hour for the first 12 hours after surgery."

c. "I need to place my hands behind my neck when I have to cough or change positions."

The nurse has provided discharge instructions to a client after radical vulvectomy. Which statement by the client indicates a need for further instruction? a. "I should avoid sexual activity for 4 to 6 weeks." b. "I should wash the perineum after each voiding." c. "It is all right to ride in a car as much as I want, as long as I am not driving the car." d. "I need to report any redness, swelling, or drainage to the health care provider."

c. "It is all right to ride in a car as much as I want, as long as I am not driving the car."

The nurse cares for a client prior to surgery. The client asks the nurse, "What is the advantage of spinal anesthesia over general anesthesia for controlling my pain?" Which is the best response by the nurse? a. "There is less risk of developing a low blood pressure." b. "Itching, a side effect of the morphine, will be minimized." c. "Your pain can be managed without making you as sleepy." d. "You will be able to maintain control of your bladder function."

c. "Your pain can be managed without making you as sleepy."

The nurse is obtaining the intershift report for a group of assigned clients. Which assigned client should the nurse monitor closely for signs of hyperkalemia? a. A client with ulcerative colitis b. A client with Cushing's syndrome c. A client admitted 6 hours ago with a 40% burn injury d. A client who has a history of long-term laxative abuse

c. A client admitted 6 hours ago with a 40% burn injury

The nurse should include which interventions in the plan of care for a client with hyperthyroidism? (Select all that apply.) a. Provide a warm environment for the client. b. Instruct the client to consume a low-fat diet. c. A thyroid-releasing inhibitor will be prescribed. d. Encourage the client to consume a well-balanced diet. e. Instruct the client that thyroid replacement therapy will be needed. f. Instruct the client that episodes of chest pain are expected to occur.

c. A thyroid-releasing inhibitor will be prescribed. d. Encourage the client to consume a well-balanced diet.

A client is admitted to the ambulatory surgery center for elective surgery. The nurse asks the client whether any food, fluid, or medication was taken today. Which medication, if taken by the client, should indicate to the nurse the need to contact the health care provider? a. A beta-blocker b. An antibiotic c. An anticoagulant d. A calcium-channel blocker

c. An anticoagulant

When performing a surgical dressing change on a client's abdominal dressing, the nurse notes an increased amount of drainage and separation of the incision line. The underlying tissue is visible to the nurse. The nurse should take which action in the initial care of this wound? a. Leave the incision open to the air to dry the area. b. Irrigate the wound and apply a sterile dry dressing. c. Apply a sterile dressing soaked with normal saline. d. Apply a sterile dressing soaked in povidone-iodine.

c. Apply a sterile dressing soaked with normal saline.

Which finding in a postoperative client would be of concern to the nurse? a. Urinary output of 40 mL/hr b. Temperature of 37.6°C (99.6°F) c. Blood pressure of 88/52 mm Hg d. Moderate drainage on the surgical dressing

c. Blood pressure of 88/52 mm Hg

A client returns to the nursing unit following a pyelolithotomy for removal of a kidney stone. A Penrose drain is in place. Which action should the nurse include in the client's postoperative plan of care? a. Positioning the client on the affected side b. Irrigating the Penrose drain using sterile procedure c. Changing dressings frequently around the Penrose drain d. Weighing dressings and adding the amount to the output

c. Changing dressings frequently around the Penrose drain

During an assessment of skin turgor in an older client, the nurse discovers that skin tenting occurs when the skin is pinched on the client's forearm. What should the nurse do next? a. Document this assessment finding. b. Call another nurse to verify this finding. c. Check skin turgor over the client's sternum. d. Call the health care provider (HCP) to obtain a prescription for fluid replacement.

c. Check skin turgor over the client's sternum.

The nurse is caring for a group of clients on the clinical nursing unit. Which client should the nurse plan to monitor for signs of fluid volume deficit? a. Client in heart failure b. Client in acute kidney injury c. Client with diabetes insipidus d. Client with controlled hypertension

c. Client with diabetes insipidus

A gastrectomy is performed on a client with gastric cancer. In the immediate postoperative period, the nurse notes bloody drainage from the nasogastric tube. The nurse should take which most appropriate action? a. Measure abdominal girth. b. Irrigate the nasogastric tube. c. Continue to monitor the drainage. d. Notify the health care provider (HCP).

c. Continue to monitor the drainage.

The nurse in a surgical unit receives a postoperative client from the postanesthesia care unit. After the initial assessment of the client, the nurse should plan to continue with postoperative assessment activities how often? a. Every hour for 2 hours and then every 4 hours as needed b. Every 30 minutes for the first hour, every hour for 2 hours, and then every 4 hours as needed c. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed d. Every 5 minutes for the first half-hour, every 15 minutes for 2 hours, ev

c. Every 15 minutes for the first hour, every 30 minutes for 2 hours, every hour for 4 hours, and then every 4 hours as needed

The nurse is preparing a client with a new diagnosis of hypothyroidism for discharge. The nurse determines that the client understands discharge instructions if the client states that which signs and symptoms are associated with this diagnosis? (Select all that apply.) a. Tremors b. Weight loss c. Feeling cold d. Loss of body hair e. Persistent lethargy f. Puffiness of the face

c. Feeling cold d. Loss of body hair e. Persistent lethargy f. Puffiness of the face

The nurse is creating a plan of care for a client scheduled for surgery. The nurse should include which activity in the nursing care plan for the client on the day of surgery? a. Avoid oral hygiene and rinsing with mouthwash. b. Verify that the client has not eaten for the last 24 hours. c. Have the client void immediately before going into surgery. d. Report immediately any slight increase in blood pressure or pulse.

c. Have the client void immediately before going into surgery.

A nurse is reviewing the assessment findings and laboratory data for a client with the syndrome of inappropriate antidiuretic hormone secretion (SIADH). The nurse understands that which symptoms are associated characteristics of this disorder? (Select all that apply.) a. Hypernatremia b. Signs of water deficit c. High urine osmolality d. Low serum osmolality e. Hypotonicity of body fluids f. Continued release of antidiuretic hormone (ADH)

c. High urine osmolality d. Low serum osmolality e. Hypotonicity of body fluids f. Continued release of antidiuretic hormone (ADH)

A nurse is caring for a client with a dysfunctional thyroid gland and is concerned that the client will exhibit a sign of thyroid storm. Which is an early indicator of this complication? a. Bradycardia b. Constipation c. Hyperreflexia d. Low-grade temperature

c. Hyperreflexia

A nurse is caring for a client with thyrotoxicosis who is at risk for the development of thyroid storm. To detect this complication, the nurse should assess for which sign or symptom? a. Bradycardia b. Constipation c. Hypertension d. Low-grade temperature

c. Hypertension

A client is admitted to a hospital with a diagnosis of diabetic ketoacidosis (DKA). The initial blood glucose level is 950 mg/dL (54.2 mmol/L). A continuous intravenous (IV) infusion of short-acting insulin is initiated, along with IV rehydration with normal saline. The serum glucose level is now decreased to 240 mg/dL (13.7 mmol/L). The nurse would next prepare to administer which medication? a. An ampule of 50% dextrose b. NPH insulin subcutaneously c. IV fluids containing dextrose d. Phenytoin for the prevention of seizures

c. IV fluids containing dextrose

The emergency department nurse is preparing a plan for initial care of a client with a diagnosis of hyperosmolar hyperglycemic syndrome (HHS). The nurse recognizes that the hyperglycemia associated with this disorder results from which occurrence? a. Increased use of glucose b. Overproduction of insulin c. Increased production of glucose d. Increased osmotic movement of water

c. Increased production of glucose

The nurse should include which interventions in the plan of care for a client with hypothyroidism? (Select all that apply.) a. Provide a cool environment for the client. b. Instruct the client to consume a high-fat diet. c. Instruct the client about thyroid replacement therapy. d. Encourage the client to consume fluids and high-fiber foods in the diet. e. Inform the client that iodine preparations will be prescribed to treat the disorder. f. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur.

c. Instruct the client about thyroid replacement therapy. d. Encourage the client to consume fluids and high-fiber foods in the diet. f. Instruct the client to contact the health care provider (HCP) if episodes of chest pain occur.

The nurse has instructed a preoperative client using an incentive spirometer to sustain the inhaled breath for 3 seconds. When the client asks about the rationale for this action, the nurse explains that this action achieves which function? a. Dilates the major bronchi b. Increases surfactant production c. Maintains inflation of the alveoli d. Enhances ciliary action in the tracheobronchial tree

c. Maintains inflation of the alveoli

A nurse is assessing a client who has had cranial surgery and is at risk for development of diabetes insipidus. The nurse would assess for which signs or symptoms that could indicate development of this complication? a. Diarrhea b. Infection c. Polydipsia d. Weight gain

c. Polydipsia

A client with a history of diabetes mellitus has a fingerstick blood glucose level of 460 mg/dL. The home care nurse anticipates that which additional finding would be present with further testing if the client is experiencing diabetic ketoacidosis (DKA)? a. Hyponatremia b. Rise in serum pH c. Presence of ketone bodies d. Elevated serum bicarbonate level

c. Presence of ketone bodies

The nurse is caring for a client admitted to the hospital with uncontrolled type 1 diabetes mellitus. In the event that diabetic ketoacidosis (DKA) does occur, the nurse anticipates that which medication would most likely be prescribed? a. Glucagon b. Glyburide c. Regular insulin d. Neutral protamine Hagedorn (NPH) insulin

c. Regular insulin

The nurse is reviewing the laboratory results for a client who is receiving magnesium sulfate by intravenous infusion. The nurse notes that the magnesium level is 5 mEq/L (2.5 mmol/L). On the basis of this laboratory result, the nurse should expect to note which in the client? a. Tremors b. Hyperactive reflexes c. Respiratory depression d. No specific signs or symptoms because this value is a normal level

c. Respiratory depression

A client preparing to go home 2 days following a right mastectomy with dissection of axillary lymph nodes asks the nurse, "What should I do to minimize my chance for complications from this surgery?" Which response should the nurse make? a. "Try to minimize moving your right arm." b. "Examine the surgical incision once a week." c. "Be sure to carry your purse over your right shoulder." d. "Avoid having blood pressures taken on your right arm."

d. "Avoid having blood pressures taken on your right arm."

The home care nurse visits a client to perform a dressing change on a leg ulcer. The client has diabetes mellitus and a history of cardiac disease and is taking one aspirin daily in addition to other medications as prescribed. The client tells the nurse that dental surgery is scheduled and asks the nurse whether the aspirin should be discontinued. The nurse should make which statement to the client? a. "The pharmacist should be called." b. "There is no risk to having such a minor surgery while taking aspirin." c. "Aspirin has no effect on the surgical procedure and may minimize discomfort." d. "Dental surgery can safely be done usually 10 days after stopping the aspirin, depending on the health care provider's preference."

d. "Dental surgery can safely be done usually 10 days after stopping the aspirin, depending on the health care provider's preference."

The home care nurse visits a client with a diagnosis of hyperparathyroidism who is taking furosemide and provides dietary instructions to the client. Which statement by the client indicates a need for additional instruction? a. "I need to eat foods high in potassium." b. "I need to drink at least 2 to 3 L of fluid daily." c. "I need to eat small, frequent meals and snacks if nauseated." d. "I need to increase my intake of dietary items that are high in calcium."

d. "I need to increase my intake of dietary items that are high in calcium."

The nurse provides dietary instructions to a client with diabetes mellitus regarding the prescribed diet. Which statement, if made by the client, indicates a need for further teaching? a. "I'll eat a balanced meal plan." b. "I need to drink diet soft drinks." c. "I'll snack on fruit instead of cake." d. "I need to purchase special dietetic foods."

d. "I need to purchase special dietetic foods."

The nurse has provided instructions for measuring blood glucose levels to a client newly diagnosed with diabetes mellitus who will be taking insulin. The client demonstrates understanding of the instructions by identifying which method as the best method for monitoring blood glucose levels? a. "I will check my blood glucose level every day at 5:00 p.m." b. "I will check my blood glucose level 1 hour after each meal." c. "I will check my blood glucose level 2 hours after each meal." d. "I will check my blood glucose level before each meal and at bedtime."

d. "I will check my blood glucose level before each meal and at bedtime."

The nurse provides instructions to a client newly diagnosed with type 1 diabetes mellitus. The nurse recognizes accurate understanding of measures to prevent diabetic ketoacidosis when the client makes which statement? a. "I will stop taking my insulin if I'm too sick to eat." b. "I will decrease my insulin dose during times of illness." c. "I will adjust my insulin dose according to the level of glucose in my urine." d. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)."

d. "I will notify my health care provider (HCP) if my blood glucose level is higher than 250 mg/dL (14.2 mmol/L)."

The nurse cares for a client who is at risk for wound dehiscence after abdominal surgery. Which action is the priority to minimize this risk? a. Administer prescribed antibiotics. b. Use sterile technique for dressing changes. c. Keep sterile saline and sterile dressings at the bedside. d. Place a pillow over the incision site during deep breathing and coughing.

d. Place a pillow over the incision site during deep breathing and coughing.

The nurse is caring for a client admitted to the emergency department with diabetic ketoacidosis (DKA). In the acute phase, the nurse plans for which priority intervention? a. Correct the acidosis. b. Administer 5% dextrose intravenously. c. Apply a monitor for an electrocardiogram. d. Administer short-duration insulin intravenously.

d. Administer short-duration insulin intravenously.

The nurse is developing a plan of care for a preoperative client who has a latex allergy. Which intervention should be included in the plan? a. Avoid using medications from glass ampules. b. Use medications that are from ampules with rubber stoppers. c. Avoid using intravenous tubing that is made of polyvinyl chloride. d. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure.

d. Apply a cloth barrier to the client's arm under a blood pressure cuff when taking the blood pressure.

A nurse is preparing a teaching plan for a client with diabetes mellitus regarding proper foot care. Which instruction should be included in the plan? a. Soak the feet in hot water. b. Avoid using a mild soap on the feet. c. Always have a podiatrist cut the toenails. d. Apply a moisturizing lotion to dry feet but not between the toes.

d. Apply a moisturizing lotion to dry feet but not between the toes.

The emergency department nurse is reviewing the laboratory test results for a client suspected of having diabetic ketoacidosis (DKA). Which laboratory result should the nurse expect to note in this disorder? a. Serum pH of 9.0 b. Absent ketones in the urine c. Serum bicarbonate of 22 mEq/L (22 mmol/L) d. Blood glucose level of 500 mg/dL (28.5 mmol/L)

d. Blood glucose level of 500 mg/dL (28.5 mmol/L)

The nurse is developing a plan of care for a client who is scheduled for a thyroidectomy. The nurse focuses on psychosocial needs, knowing that which is likely to occur in the client? a. Infertility b. Gynecomastia c. Sexual dysfunction d. Body image changes

d. Body image changes

A preoperative client has received a dose of scopolamine as prescribed by the anesthesiologist. The nurse should assess the client for which anticipated side effect of this medication? a. Diaphoresis b. Pupillary constriction c. Increased urinary output d. Dry oral mucous membranes

d. Dry oral mucous membranes

An external insulin pump is prescribed for a client with diabetes mellitus. When the client asks the nurse about the functioning of the pump, the nurse bases the response on which information about the pump? a. It is timed to release programmed doses of either short-duration or NPH insulin into the bloodstream at specific intervals. b. It continuously infuses small amounts of NPH insulin into the bloodstream while regularly monitoring blood glucose levels. c. It is surgically attached to the pancreas and infuses regular insulin into the pancreas. This releases insulin into the bloodstream. d. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.

d. It administers a small continuous dose of short-duration insulin subcutaneously. The client can self-administer an additional bolus dose from the pump before each meal.

The nurse is caring for a client whose magnesium level is 3.5 mEq/L (1.75 mmol/L). Which assessment finding should the nurse most likely expect to note in the client based on this magnesium level? a. Tetany b. Twitches c. Positive Trousseau sign d. Loss of deep tendon reflexes

d. Loss of deep tendon reflexes

A client with a gastric ulcer is scheduled for surgery. The client cannot sign the operative consent form because of sedation from opioid analgesics that have been administered. The nurse should take which most appropriate action in the care of this client? a. Obtain a court order for the surgery. b. Have the charge nurse sign the informed consent immediately. c. Send the client to surgery without the consent form being signed. d. Obtain a telephone consent from a family member, following agency policy.

d. Obtain a telephone consent from a family member, following agency policy.

A client arrives in the hospital emergency department complaining of severe thirst and polyuria. The client tells the nurse that she has a history of diabetes mellitus. A blood glucose level is drawn, and the result is 685 mg/dL (39.1 mmol/L). Which intervention should the nurse anticipate to be prescribed initially for the client? a. Glyburide via the oral route b. Glucagon via the subcutaneous route c. Insulin aspart via the subcutaneous route d. Regular insulin via the intravenous (IV) route

d. Regular insulin via the intravenous (IV) route

A client recovering from an exacerbation of left-sided heart failure is experiencing activity intolerance. Which change in vital signs during activity would be the best indicator that the client is tolerating mild exercise? a. Oxygen saturation decreased from 96% to 91%. b. Pulse rate increased from 80 to 104 beats per minute. c. Blood pressure decreased from 140/86 to 112/72 mm Hg. d. Respiratory rate increased from 16 to 19 breaths per minute.

d. Respiratory rate increased from 16 to 19 breaths per minute.

A client newly diagnosed with diabetes mellitus has been stabilized with daily insulin injections. A nurse prepares a discharge teaching plan regarding the insulin and plans to reinforce which concept? a. Always keep insulin vials refrigerated. b. Ketones in the urine signify a need for less insulin. c. Increase the amount of insulin before excessive exercise. d. Systematically rotate insulin injections within 1 anatomical site.

d. Systematically rotate insulin injections within 1 anatomical site.

The nurse is conducting preoperative teaching with a client about the use of an incentive spirometer. The nurse should include which piece of information in discussions with the client? a. Inhale as rapidly as possible. b. Keep a loose seal between the lips and the mouthpiece. c. After maximum inspiration, hold the breath for 15 seconds and exhale. d. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.

d. The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees.