Med Surg Exam 1

The nurse is caring for a client with type 2 diabetes mellitus. One hour after taking an oral diabetic medication, the client becomes nauseated and vomits. What is the initial action of the nurse?

Monitor blood glucose closely, and assess for signs of hypoglycemia.

The nurse has prepared hydromorphone 1 mg I.V. for a client reporting pain 7/10. Just prior to administration, the client requests an oral pain medication instead. What is the priority action by the nurse?

Ask another nurse to witness the waste of the prepared medication into the sink.

A client's blood glucose level is 45 mg/dl (2.5 mmol/L). The nurse should be alert for which signs and symptoms?

coma, anxiety, confusion, headache, and cool, moist skin

A client is being evaluated for hypothyroidism. During assessment, the nurse should stay alert for

decreased body temperature and cold intolerance.

The nurse is assigned to care for the following clients. Which client should the nurse see first?

a client diagnosed with hypothyroidism and a heart rate of 48 beats per minute

Which mediation can the nurse administer through a nasogastric (NG) tube?

acetaminophen

A nurse is teaching a client about how to recognize when treatment for hypothyroidism is effective. Which statement from the client would indicate that the nurse's teaching has been effective?

"I will start feeling more energetic."

A client newly diagnosed with hypothyroidism asks the nurse how long it will be necessary to take the prescribed levothyroxine. What should the nurse tell the client?

"It will be necessary to take the medication for the rest of your life."

A nurse is teaching a client about type 2 diabetes mellitus. What information would reduce a client's risk of developing this disease?

"Maintain weight within normal limits for your body size and muscle mass."

The laboratory comes to draw an Hgb A1c. The client asks the nurse what this test represents. Which statement would be correct?

"This test reflects the average blood glucose over a period of approximately 2-3 months."

A nurse completes preoperative teaching for a client scheduled for a cholecystectomy. The client states, "If I lie still and avoid turning, I will avoid pain. Do you think this is a good idea?" What is the nurse's best response?

"Turn from side to side every 2 hours, and the nurse will administer pain medication to assist in movement."

A school nurse is assessing an obese 10-year-old child who wants to lose weight. What question will be most important for the nurse to ask to develop a realistic plan of care?

"What kinds of foods do your parents serve at meal times and for snacks?"

A client whose physical findings suggest a hyperpituitary condition undergoes an extensive diagnostic workup. Test results reveal a pituitary tumor, which necessitates a transsphenoidal hypophysectomy. The evening before the surgery, the nurse reviews preoperative and postoperative instructions given to the client earlier. Which postoperative instruction should the nurse emphasize?

"You must avoid coughing, sneezing, and blowing your nose."

The child's provider orders 720 ml of total parenteral nutrition (TPN) to be infused over the next 24 hours. The nurse will record TPN intake of how many milliliters at the end of the eight hour shift? Record your answer using a whole number.

240

The nurse is caring for a client in the medical unit. The nurse receives a health care provider's order for hydrocortisone 100 mg intravenously at a rate of 10 cc/hour for a client in acute adrenal crisis. The nurse understands that this treatment is common in clients with which disease process?

Addison's disease

A client with type 1 diabetes presents with a decreased level of consciousness and a fingerstick glucose level of 39 mg/dl (2.2 mmol/L). His family reports that he has been skipping meals in an effort to lose weight. Which nursing intervention is most appropriate?

Administering 1 ampule of 50% dextrose solution, per physician's order

A client with cancer-related pain has been prescribed a narcotic analgesic to be given around the clock. The client is competent and has been actively involved in decisions regarding care. What should the nurse do if the client refuses the next dose of analgesia?

Document the client's choice and re-assess pain in 1 hour.

A nurse is planning care for a client newly diagnosed with diabetes mellitus type 1. Which statement illustrates an appropriate outcome criterion?

The client will correctly demonstrate blood glucose testing prior to discharge.

A client receiving chemotherapy is nauseated and has lost 15 pounds (6.8 kg) in one month. Which nutritional instruction would the nurse include in the plan of care?

Eat frequent but small meals.

The nurse is preparing to initiate an enteral feeding through a percutaneous endoscopic gastrostomy (PEG) tube. What intervention will the nurse include in the client's plan of care?

Ensure patency of the tube.

A client with diabetes is found unconscious after the morning dose of insulin. What would be a priority nursing intervention at this time?

Initiate treatment for hypoglycemia as a result of insulin.

The nurse is caring for a client with diabetes insipidus (DI). What is the nurse's priority intervention?

Maintaining adequate hydration

A client with a subdural hematoma needs a feeding tube inserted due to inadequate swallowing ability. How would the nurse best explain this to the family?

Nutrients are needed; however, eating and drinking without control of the swallowing reflex can result in aspirational pneumonia.

A 79-year-old client has been admitted to the unit. The client is diagnosed with a left hip fracture secondary to a fall, and is scheduled for a left total hip replacement (LTHR). The client's comorbidities are hypertension and diabetes. The client is a full code with no known allergies (NKA). What is the nurse's priority action for this client?

Pain management

The nurse is reviewing the chart of a client with type 2 diabetes prior to a scheduled appointment. The chart states:Progress notes10/15/160245Client states that he has not been following his prescribed diabetes management program for the past 2 to 3 months. Client is aware of his blood glucose monitoring regimen and diet but has difficulty integrating each into his routines. Client denies recent changes in urinary function, sensation or vision.How can the nurse best determine this client's glycemic control since the last assessment?

Review the results of the client's HbA1c.

A client has been admitted with type 2 diabetes mellitus and asks to have the local medicine man come and help decide what traditional aboriginal medicines could help. What are the appropriate nursing interventions based on this client's request?

Suggest that the client inform and discuss with the interprofessional team how traditional therapies could be integrated into the plan of care.

A nurse explains to a client with thyroid disease that the thyroid gland normally produces

T3, thyroxine (T4), and calcitonin.

A white female client is admitted to an acute care facility with a diagnosis of stroke. Her history reveals bronchial asthma, exogenous obesity, and iron deficiency anemia. Which history finding is a risk factor for stroke?

being obese

A nurse is caring for a client with an endotracheal tube who receives enteral feedings through a feeding tube. Before each tube feeding, the nurse checks for tube placement in the stomach as well as residual volume. The purpose of the nurse's actions is to prevent

aspiration.

A nurse is teaching a client with type 1 diabetes how to treat adverse reactions to insulin. To reverse hypoglycemia, the client ideally should ingest an oral carbohydrate. However, this treatment isn't always possible or safe. Therefore, the nurse should advise the client to keep which alternate treatment on hand?

glucagon

A client with a progressively enlarging neck comes into the clinic. The client mentions that they have been in a foreign country for the previous 3 months and that they didn't eat much while there because they didn't like the food. The client also mentions that they become dizzy when lifting their arms to do normal household chores or when dressing. What endocrine disorder should the nurse expect the physician to diagnose?

goiter

What important considerations would the nurse make when teaching and caring for a client newly diagnosed with diabetes mellitus?

involving the client in the development of the teaching plan and encouraging questions and active participation

Which intervention is the most critical for a client with myxedema coma?

maintaining a patent airway

A child is receiving total parenteral nutrition (TPN). During TPN therapy, the most important nursing action is:

monitoring the blood glucose level closely.

The nurse is assigned a client newly diagnosed with type 2 diabetes. Which tasks should the nurse delegate to a unlicensed assistive personnel (UAP)?

reminding the client to check the glucose level before each meal

A client is diagnosed with syndrome of inappropriate antidiuretic hormone (SIADH). Laboratory results reveal serum sodium level 130 mEq/L and urine specific gravity 1.030. Which nursing intervention helps prevent complications associated with SIADH?

restricting fluids to 800 ml/day

A nurse is discussing nutrition and weight control with clients during a class about diabetes. Which statement best reflects the purpose of nutritional management of diabetes?

to maintain blood glucose levels close to the normal range to reduce risk for long-term complications

Early this morning, a client had a subtotal thyroidectomy. During evening rounds, the nurse assesses the client, who now has nausea, a temperature of 105° F (40.5° C), tachycardia, and extreme restlessness. What is the most likely cause of these signs?

thyroid crisis

A nurse is assessing a client with hyperthyroidism. What findings should the nurse expect?

weight loss, nervousness, and tachycardia